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Full text of "Text-book of ophthalmology"

I 



, I : 



CORNE LL UNIV ERSITY 

THE 

FOUNDED BY 

ROSWELL P. FLOWER 

for the use of the 
N. Y. STATE. VETERINARY COLLEGE 

1897 



This Volume is the Gift of 

.])_%. ..Leon-S-vBeardsi-ev 




3 1924 104 224 724 




The original of tiiis bool< is in 
tine Cornell University Library. 

There are no known copyright restrictions in 
the United States on the use of the text. 



http://archive.org/details/cu31924104224724 



TEXT- BOOK OF 

OPHTHALMOLOGY 



BY 

Dr. ERNEST FUCHS 

PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF VIENNA 



authorized translation, revised from the 
seventh enlarged and improved german edition 

By a. DUANE, M. D. 

ASSISTANT SURGEON OPHTHALMIC AND AURAL INSTITUTE 
NEW YORK 



WITH TWO HUNDRED AND SEVENTY-SEVEN 
ILLUSTRA TIONS 



SECOND AMERICAN EDITION 



NEW YORK 
D. APPLETON AND COMPANY 

1901 



Copyright, 1892, 1899, 

bt d. applbton and company. 



Electeotyped and Printed 
AT THE Applbton Press, U. S. A. 



PREFACE TO FIRST EDITION. 



No apology seems needed for presenting to American readers the 
translation of a book so well and so favorably known as Prof. Fuch's 
Lehrbuch der Augenheilkunde. The care and judicious spirit govern- 
ing the selection and presentation of facts, the thoroughness and fresh- 
ness of the information, and the scientific accuracy which characterize 
the original, have won for it the first place among ophthalmological 
text-books. To t^ese essential properties there is superadded one 
scarcely less important in a book of this character, namely, a clear, 
concise, and pleasing style. In the endeavor to make his version 
worthy of the original in this important regard, the translator has 
taken considerable liberties with the German text, and has not hesi- 
tated to alter grammatical relations, substitute and interpolate words, 
and in other ways depart from the strict letter of his model whenever 
it has seemed to him that clearness and the necessities of the English 
idiom required the change. Upon this point he is glad to say that he 
has the entire approval of Dr. Fuchs, who has not only given his au- 
thorization to the work of translation, but has been good enough to 
look over and indulgent enough to commend that portion of the book 
submitted to his inspection. 

In consonance with his views of a translator's duties, the author of 
the present version has made only such additions as seemed necessary 
to adapt the book to American readers. These additions are every- 
where distinguished by being inclosed in brackets, and, in the case of 
footnotes, by having the letter D appended to them. The translator 
alone is responsible for such insertions ; at the same time, it is but fair 
to state that a number of them have been submitted to Dr. Fuchs and 
have received his approval. 

The appendix containing the cuts of instruments is also matter 
inserted by the translator. These cuts (and also the two on page 722) 



iv PEEP ACE TO THE FIRST EDITION. 

have been kindly furnished by Tiemann & Co., and by E. B. Meyro- 

witz, the well-known instrument makers of this city, to whom the 

translator desires here to make suitable acknowledgments for the 

courtesy extended. 

It is the hope of the translator that he has succeeded in faithfully 

reproducing a work the many excellences of which should command 

for it a wide circulation in this country, as they have already done in 

Europe. 

A. DuANE, M. D. 

25 East Thirty-first Street, New York, July 6, 1892. 



PKEFACE TO THE SECOND EDITION. 



SiisrcE the first edition of this book was published five German 
editions have been issued. Each of these has been characterized by 
the addition of important new matter and by the thorough revision of 
the old. This is particularly the case with the last or seventh edition, 
which, in addition to the merits of lucidity, judicious treatment of the 
subject, and excellence of proportion and balance, that have always 
characterized Prof. Fuch's treatise, bears everywhere the marks of the 
most thorough revision, of additions and corrections, bringing the book 
up to date in all its parts, so that it presents an excellent summary of 
ophthalmological science as we know it to-day. 

Although alterations will be found on almost every page, the most 
marked changes will be met with in the sections on functional exam- 
ination, the pathology of corneal and conjunctival diseases (especially 
the parts relating to ulcus serpens and diphtheria), and the diseases of 
the fundus. Over eighty illustrations have been added. 

The translator has thought it proper to insert two new sections : 
§ 125 A (page 616), upon heterophoria, and § 148 A (page 734), upon the 
use of homatropine and other cycloplegics and the general subject of 
the correction of refractive errors. For these insertions, as well as 
all others of his own (distinguished as in the first edition by being 
inclosed in brackets) the translator is wholly responsible. 

In view of the favorable reception accorded the first edition of this 

work in this country, the translator has little hesitation in offering the 

second, particularly as it represents an essentially improved form of a 

work which has already proved to be of value to so many — and of a 

work, moreover, which, in matter, scope, and treatment, contains so 

much that appeals both to the professed ophthalmologist and to the 

general practitioner. 

Alexander Duane. 

49 East Thirtieth Street, New York, 
March 1, 1899. 

V 



OONTEI^TS. 



PAET I. 

EXAMINATION OF THE EYE. 
CHAPTER I. 

Objective Examination of the Eye. 

PAGE 

Examination of the eyes 1 

Ophthalmoscopy 4 

Principle of the ophthalmoscope 5 

Method of examination 6 

Luminosity of the pupil 8 

Application of the ophthalmoscope— characters of normal fundus . . 9 

Examination of the refracting media 16 

Determination of the refraction by objective methods (ophthalmoscope, 
skiascopy) .18 

CHAPTER II. 

Functional TESTiNa. 

Central and peripheral vision .37 

Examination of the field of vision 28 

Extent of the field of vision 31 

Light sense 34 

Simulation of blindness 35 



PAET 11. 

DISEASES OF TEE EYE. 

CHAPTER L 

Diseases of the Conjunctita. 

Anatomy of the conjunctiva 38 

Conjunctivitis catarrhalis ** 

Acuta 44 

Chronica _ 

Pollicularis ^'^ 

Conjunctivitis blennorrhoica acuta ^4 

Blennorrhcea adultorum ■ • • • • ^^ 

Blennorrhoea neonatorum ^^ 

vii 



viii CONTENTS. 

PAGE 

Conjunctivitis trachomatosa ^^ 

Conjunctivitis diphtherica 86 

Croupous membranes on the conjunctiva 90 

Conjunctivitis eezematosa . 93 

Acute exanthemata associated with conjunctivitis 103 

Chronic exanthemata associated with conjunctivitis 102 

Acne rosacea conjunctivae 102 

Pemphigus conjunctivae 102 

Lupus conjunctivae 103 

Vernal catarrh 103 

Amyloid degeneration of the conjunctiva 106 

Tuberculosis of the conjunctiva 107 

Ulcers of the conjunctiva . . . 109 

Injuries of the conjunctiva ' 110 

Pterygium 112 

Pseudo-pterygium 116 

Symblepharon - 117 

Xerosis. . 120 

Extravasation of serum and blood beneath the conjunctiva .... 122 

Tumors of the conjunctiva 124 

Affections of the plica semilunaris and caruncle 129 



CHAPTER II. 

Diseases of the Cornea. 

Anatomy of the cornea 130 

Clinical examination of the cornea 184 

Inflammation of the cornea 136 

General statement . . . ■ 136 

Subdivision of keratitis 144 

Suppurative keratitis 145 

Ulcer of the cornea 145 

Ulcus serpens corneas 163 

Keratitis e lagophthalmo 174 

Keratomalacia 175 

Keratitis neuroparalytica 177 

Non-suppurative keratitis 180 

Pannus 180 

Keratitis with the formation of vesicles (herpes febrilis, herpes zos- 
ter, and keratitis vesiculosa) 181 

Kei-atitis punctata superficialis 183 

I Parenchymatous keratitis 184 

Keratitis profunda 194 

Sclerosing keratitis 195 

Keratitis springing from the posterior surface of the cornea . . 195 

Deep keratitis in irido-cyclitis 196 

Deep scrofulous infiltrates 196 

Keratitis marginalis profunda 197 

Striate opacity of the cornea 197 

Injuries of the cornea 198 

Foreign bodies in the cornea 198 

Solutions of continuity of the cornea 199 



CONTENTS. ix 

PAGE 

Injuries of the cornea by caustic agents and burns 201 

Opacities of tlie cornea 203 

EctasiJB ol the cornea 212 

Staphyloma of the cornea 212 

Kerateotasia 223- 

Keratoconus 223 

Keratoglobus 224 

Tumors of the cornea 225 

CHAPTER III. 

Diseases of the Solera. 

Anatomy of the sclera 226 

Inflammation of the sclera 227 

Superficial forms of scleritis (episcleritis) 227 

Deep forms of scleritis 329 

Injuries of the sclera 233 

Foreign bodies in the eye 235 

EctasifB of the sclera 244 

Ulcers and tumors of the sclera 350 

CHAPTER IV. 

Anatomy and Phtsioloot of the Uvea — Embryology of the Eye. 

Anatomy of the uvea 251 

Iris 251 

Ciliary body 256 

Chorioid 363 

Circulation and metabolism of the uvea 365 

Blood-vessels 265 

Lymph-passages 368 

Nutrition of the eye 370 

Intra-ocular pressure 272 

Participation of the uvea in the visual act 374 

Function of iris ; reaction of pupil ; mydriatics and miotics ; function of 

ciliary body and chorioid 374 

Development of the eye 383 

CHAPTER V. 

Diseases of the Ibis and op the Ciliary Body. 

Inflammation (iritis, cyclitis, irido-cyclitis) 389 

Symptoms of iritis 289 

Symptoms of cyclitis 893 

Differential diagnosis between iritis and cyclitis 297 

Course and termination of iritis and cyclitis 302 

Etiology and varieties of iritis and cyclitis ; sympathetic irritation and 

ophthalmia 308 

Treatment of iritis and cyclitis 317 

Injuries of the iris 323 

Tumors of the iris and ciliary body (including cysts and tuberculosis) . . 326 



X CONTENTS. 

PAGE 

Disorders of motility of the iris 331 

Mydriasis 332 

Miosis 333 

Paralysis of the sympathetic 333 

Hippus . . 333 

Congenital anomalies of the iris 334 

Persistent pupillary membrane 334 

Coloboma iridis 334 

Irideremia 335 

Ectopia pupillse 335 

CHAPTER VI. 

Diseases of the Chomoid. 

Inflammation of the chorioid 337 

Chorioiditis exudativa 338 

Chorioiditis and irido-chorioiditis suppurativa ; metastatic ophthalmia ; 

atrophy and phthisis of eyeball 346 

Detachment of the chorioid 352 

Rupture of the chorioid 352 

Tumors of the chorioid 353 

Tuberculosis of the chorioid 356 

Congenital anomalies of the chorioid 357 

Albinism 361 

CHAPTER VII. 
Glaucoma. 

General considerations 363 

Primary glaucoma 367 

Glaucoma inflammatorium 3g7 

Glaucoma simplex 373 

Hydrophthalmus 374 

Theories of glaucoma 37g 

Anatomy of glaucoma 333 

Treatment of primary glaucoma 385 

Secondary glaucoma 391 

Diminution of the intra-ocular pressure . 393 

CHAPTER VIII. 

Diseases of the Lens. 

Anatomy of the lens 394 

Opacities of the lens, cataract 397 

General considerations 397 

Clinical forms of cataract 402 

Anterior polar cataract 403 406 

Posterior polar cataract 493 406 

Circumscribed opacities 493 

Perinuclear (or lamellar) cataract 404 407 

Cortical cataract 406 408 

Progressive cataracts (senile cataract) 4Q8 



CONTENTS. xi 

PAGE 

Etiology of cataract 417 

Treatment of cataract 422 

Changes of position of the lens 425 

Lenticonus 430 

CHAPTER IX. 

Diseases of the Vitbeous. 

Anatomy of the vitreous 431 

Opacities of the vitreous 431 

Liquefaction of the vitreous 483 

Foreign bodies in the vitreous ; persistent hyaloid artery ; entozoa . . . 483 

CHAPTER X. 

Diseases of the Retina. 

Anatomy and physiology of the retina 437 

Inflammation of the retina ; retinitis 440 

Hyperaamia of the retina 443 

AnfBmia of the retina ; quinine amaurosis 443 

Hffimorrhages into the retina 443 

Embolism of the central artery 445 

Thrombosis of the central vein 447 

Varieties of retinitis ; uremic amaurosis ; retinal disease of infants • . 449 

Atrophy of the retina ; retinitis pigmentosa 454 

Anatomical changes in inflammation and atrophy of retina . , . 457 

Detachment of the retina 458 

Glioma of the retina 464 

Injuries of the retina 466 

CHAPTER XI. 

Diseases of the Optic Nerve. 

Anatomy of the optic nerve 469 

Intra-ocular division 469 

Orbital division 471 

Intracranial division 473 

Continuation of the fibers to the cerebral cortex ; decussation of the optic 

nerves ; hemiopia 473 

Inflammation of the optic nerve 481 

Neuritis intra-ocularis ; hyperaemia of optio nerve ; neuro-retinitis . . 482 

Retrobulbar neuritis ; tobacco amblyopia and other toxic amblyopias . 488 

Strychnine in eye diseases 491 

Atrophy of the optic nerve 491 

Injuries of the optic nerve 493 

Tumors of the optic nerve 493 

Anatomy of affections of the optic nerve 494 

Disturbances of vision without apparent lesion 495 

Congenital amblyopia 495 

Amblyopia ex anopsia 496 

Hemeralopia and nyctalopia 496 

Amblyopia and amaurosis of central origin 499 



xii CONTENTS. 

PAGE 

Scintillating scotoma . 499 

Hysterical amblyopia and asthenopia 500 

Color blindness 501 

CHAPTER XII. 
Diseases of the Lids. 

Anatomy and physiology of the lids 509 

Inflammation of the skin of the lids 518 

Exanthemata (erysipelas, herpes zoster, eczema) .... 518, 532 

Phlegmonous inflammation 531 

Ulcers of the skin of the lids 533 

Elephantiasis of the lids 533 

Chromidrosis 523 

CEderaa of the lids 533 

Inflammation of the border of the lids 526 

Hypersemia 626 

Blepharitis squamosa and ulcerosa 526 

Phthiriasis palpebrarum 581 

Diseases of the palpebral glands 583 

Hordeolum 582 

Chalazion 533, 535 

Infarcts of the Meibomian glands 535 

Affections of the tarsus 536 

Anomalies of position and connection of lids 537 

Trichiasis and distichiasis 537 

Entropion 5G9 

Ectropion 541 

Ankyloblepharon 544 

Symblepharon .544 

Blepharophimosis 544 

Lagophthalmus 54(3 

Diseases of the palpebral muscles ,1548 

Spasm of the orbicularis (blepharospasm) 548 551 

Paralysis of the orbicularis . _ , 549 

Paralysis of the levator palpebra3 superioris (ptosis) .... 550 552 

Spasm and paralysis of Miiller's muscle 553 

Injuries of the lids 554 

Tumors of the lids g5g 

Congenital anomalies of the lids (coloboraa, epicanthus, etc.) .... 558 

CHAPTER XIII. 

Diseases of the Lachrymal Orgahs, 

Anatomy and physiology ggO 

Blennorrhcea of the lachrymal sac 5g4 5^3 

Dacryocystitis 570^ 574 

Diseases of the lachrymal gland 57^^ 

Affections of puneta and canaliouli 573 

Trachoma and tuberculosis of lachrymal sac 573 

Treatment of lachrymal disease 573 

Epiphora and increase of lachrymal secretion 573 

Abolition of lachrymal secretion 575 



CONTENTS. xiii 

CHAPTER XIV. 
Disturbances of Motility of the Eye. 

PAGR 

Anatomy and physiology of the ocular muscles 57G 

Anatomy of muscles 576, 585 

Action of muscles 578, 580 

Orientation and diplopia 580, 590 

Measurement of excursions of eyes ; field of fixation 587 

Nerves of ocular muscles 588 

Binocular and stereoscopic vision ; overcoming of prisms ; divergence and 

convergence 590 

Paralysis of the ocular muscles 594 

Latent disturbances of equilibrium ; heterophoria 613, 616 

Squint 627 

Nystagmus 638 

Tonic spasms of ocular muscles 640 

CHAPTER XV. 
Diseases of the Orbit. 

Anatomy of the orbit 641 

Position of the eyeball in the orbit ; exophthalmus 643 

Enophthalmus 645 

Inflammation 645 

Inflammation of the bony wall and the periosteum .... 645, 648 

Inflammation of the cellular tissue ; cellulitis 647 

Thrombosis of the cavernous sinus . 649 

Tenonitis 649 

Injuries of the orbit 650 

Contusion of the eye ; summary of appearances 653 

Basedow's disease 653 

Tumors of the orbit ; pulsating exophthalmus 655 

Dilatation of the cavities adjoining the orbit 659 



PAET III. 

ANOMALIES OF REFRACTION AND ACCOMMODATION. 
Introduction 661 

CHAPTER I. 
The Theory of Glasses. 

Varieties and properties of lenses 663 

Numbering of glasses 666 

CHAPTER II. 
Optical Properties op the Normal Bye. 

Refraction 669 

Visual acuity 670 

Accommodation 674 

Measurement of accommodation 679 

Changes of the accommodation in age ; presbyopia ..... 686 



xiv CONTENTS. 

CHAPTER III. 

Myopia. p^^e 

Nature and determination . 690 

Typical myopia 694 

CHAPTER IV. 

Hypeemetbopia. 

Nature and determination ^5 

Typical hypermetropia 710 

CHAPTER V. 
Astigmatism — The Correction of Refractive Errors. 

Regular astigmatism 716, 721 

Irregular astigmatism 720 

Determination of astigmatism . 731 

Oyoloplegios and the correction of refractive errors 724 

Anisometropia 726 

CHAPTER VI. 
Anomalies of Accosihodation. 

Paralysis of accommodation 728 

Spasm of accommodation . 731 



PAET IV. 

■ OPERATIONS. 
CHAPTER I. 
General Remarks. 

The antiseptic method in eye operations 733, 740 

Anesthesia in operations 735 

Instruments for supporting the lids 735 

Character and shape of incisions in the eyeball 735, 741 

Maintenance of proper position of the iris 736, 743 

Haemorrhage in operations 737, 745 

After-treatment of operations 738, 745 

Regular healing of operation wounds . . . . • . . . . 733 

Irregular healing of operation wounds 739 

Suppuration of wound after operations 74O 

Inflammation of the uvea after operations 74O 

Collapse of the cornea 744 

CHAPTER II. 

Operations upon the Eyeball. 

Paracentesis of the cornea 746 

Paracentesis of the sclera ; sclerotomy 747 

Iridectomy 748 



CONTENTS. XV 

PAGE 

Iridotomy 755 

Discission of soft cataract 756 

Discission of membranous cataract 759 

Extraction of cataract 760 

Simple linear extraction 760 

Flap extraction . 761 

Early operations for cataract 767 

Depression 767 

Keclination . 767 

Daviel's operation . 768 

Beer's operation 768 

The operations of Von Graefe and others ...... 768 

Erythropsia 771 

CHAPTER III. 

Operations upon the Adnexa Bulbi. 

Squint operations ; tenotomy and advancement 772 

Enucleation of the eyeball 780 

Artificial eye 783, 784 

Exenteratio bulbi 784 

Optico-ciliary neurotomy 785 

Exenteration of the orbit 785 

Operations for trichiasis 786 

Canthoplasty 792 

Tarsorrhaphy 793 

Operations for entropion 795 

Operations for ectropion 797 

Blepharoplasty 798 

Operations for ptosis 801 



APPENDIX. 

Instruments used in Ophthalmolooy : 

Instruments for opening the eye and keeping it in place 
Instruments for operations upon the lids . 
Instruments for strabismus and enucleation 
Instruments for lachrymal stricture . 
Instruments for removing foreign bodies 

Tattooing needles 

Instruments for iridectomy and iridotomy 
Instruments for paracentesis and discission 
Instruments for cataract extraction 

Ophthalmoscopes 

Instruments for skiascopy . 
The ophthalmometer and keratoscope . 
The perimeter ..... 
Instruments for muscle-testing . 



805 
806 
807 
808 
809 
809 
810 
811 
813 
814 
816 
818 
819 
830 



PAET I. 
EXAMINATIOI^ OF THE EYE. 



CHAPTER I. 
OBJECTIVE EXAMINATION OF THE EYES. 

1. The examination of a patient's eyes is begun after establishing 
the history of the case. In making this examination too much stress 
can not be laid upon the necessity of proceeding systematically, since 
otherwise important matters can very readily be overlooked. We first 
examine the patient with regard to his general physical condition as 
well as with regard to the expression of his countenance, and then, in 
observing the eyes themselves, proceed gradually from the superficial 
parts — lids, conjunctiva, and cornea — to the deeper portions. 

In respect to the lids, there are to be considered their position and 
mobility, the breadth -of the fissure between them and their power of 
closing. The character of the skin lining the lids is examined, and 
especially at their margins, where pathological changes are most often 
found. Apart from the symptoms of inflammation, which are local- 
ized with especial frequency at the borders of the lids, the things 
that we must look for are whether the palpebral edges have not pos- 
sibly lost their sharply defined form and outline, whether the cilia are 
correctly placed, and also whether the puncta dip properly into the 
lacus lacrymalis. At the same time, we must not neglect to investi- 
gate the region of the tear sac. Should simple inspection disclose no 
alteration, it is yet often possible, by pressure with the fingers in this 
region, to make the contents of the diseased sac exude through the 
puncta. 

The examination of the eyeball itself is often rendered very diffi- 
cult by strong spasm of the lids — blepharospasm. This is especially 
the case in children who, the more the physician attempts to draw the 
lids apart, squeeze them the more tightly together. In these cases the 
forcible separation of the lids calls for the greatest caution, since, if 
this is not observed, and a deeply penetrating ulcer is present, it is easy 
to cause a sudden perforation of the cornea, nay, even the extrusion of 
the lens from the eye. By dropping a solution of cocaine between the 
1 1 



2 EXAMINATION OF THE EYE. 

slightly parted lids we try to diminish their sensitiveness ; and for th& 
separation of the lids we can, with advantage, use Desmarre's elevator, 
with which we shall less readily inflict an injury than we should do if,, 
in using the fingers, we exerted too great a pressure upon the eyeball. 
Finally, in many cases it is only by means of narcosis that we can ob- 
tain a sufficiently satisfactory view of the eyes. In spite of all these 
difficulties we should not be deterred from insisting upon an exact 
examination of the eyes at the patient's first visit, in order to establish 
the diagnosis and prognosis and to determine the treatment. 

In regard to the eyeball itself, we must first satisfy ourselves whether 
its situation in the orbit, its position in respect to the other eye, its 
size, and its mobility are normal or not. 

The conjunctiva of the lids can be brought into view by everting 
the latter. -With the lower lid, it is sufficient for this purpose to simply 
draw it down, while the patient is told at the same time to look up. 
With the upper lid, eversion requires a certain degree of skill, which 
must be obtained by practice. It is the more important to acquire this 
facility, since it is just the conjunctiva of the upper lid that generally 
affords the best evidence for the diagnosis of conjunctival diseases: 
the thickening of the conjunctiva, the uneven surface, the formation 
of cicatrices, which are characteristic of trachoma, are here most easily 
to be perceived. Further, the eversion of the upper lid is very fre- 
quently necessary for the removal of foreign bodies. 

In the examination of the cornea, besides a careful inspection (if 
need be, with a magnifier, such as that of Hartnack), there are two 
main artifices in use — examination of the corneal reflex and lateral 
illumination. To examine the corneal reflex signifies nothing more 
than to direct the eye in such a manner that the reflection of a 
window placed opposite it is visible upon the cornea (in Pig. 30 the 
image of four window panes is seen upon the upper and outer quad- 
rant of the cornea). By causing the eye to follow the movements of a 
finger held before it, the reflection is gradually brought upon different 
portions of the corneal surface, of whose curvature and smoothness we 
in this way obtain an impression. 

Lateral illumination consists in the concentration of light upon a 
certain portion of the cornea by means of a convex lens. This impor- 
tant method, although already employed by Himly, Mackenzie, and 
Sanson, was yet very little known formerly, and first obtained general 
currency through the efforts of Helmholtz. A light (candle or lamp) 
is placed beside and somewhat in front of the patient. Then, by the 
aid of a strong convex lens (of 15-30 D.), the rays are concentrated to 
a cone of light, whose apex is made to fall upon the portion of the 
cornea to be examined. This method is designated as focal illumina- 
tion, because the point to be illuminated is brought into the focus of 
the lens. This point stands out with special distinctness because, on 



OBJECTIVE EXAMINATION OP THE EYES. 3 

the one hand, a great quantity of light is concentrated upon it, and 
because, on the other hand, the parts immediately surrounding it re- 
main almost completely in darkness. On this latter ground, lateral 
illumination gives the most advantageous result if in its application 
the room is darkened. By lateral illumination we can recognize 
opacities in the cornea which are perceptible in no other way. The 
iris, too, and the lens as well, can be examined in this way by vary- 
ing the depth to which the light is projected. By so doing we have 
not merely the advantage of getting very sharp images, but also, from 
the fact that we can at will vary the depth to which the apex of the 
conical sheaf of rays is projected, we get information as to the depth 
at which the changes that we observe are situated. A handier method 
of lateral illumination is furnished by the lamp of Priestley Smith. 
This carries in its center a small candle as a source of light ; a 
strong convex lens let into the side of the lamp serves for the pro- 
duction of the cone of light. 

In addition to the appearance of the cornea we have further to 
examine its sensitiveness, which is best done by touching it with the 
point of a thread. 

The anterior chamber must be examined more especially in respect 
to its depth — that is, whether it is shallower or deeper, as a whole, or 
whether possibly it is of unequal depth. Further, we look for any 
abnormal matters which may be present in the chamber, such as an 
exudate, blood, foreign bodies, etc. 

In the iris its color as well as the clearness of its markings must be 
observed. For the recognition of adhesions the instillation of atro- 
pine is often requisite. We inspect the active movements (reaction) 
of the iris as well as any passive movement that may be present 
(tremulousness of the iris in movements of the eyeball). In order to 
determine the reaction of the iris to light, we first cover the eye by 
holding the hand before it, and then see whether, upon suddenly re- 
moving the hand, the pupil contracts (direct reaction). Then we see 
if the pupil of the eye under examination reacts when the other eye 
is alternately illuminated and shaded (consensual reaction). To keep 
the eye still while being thus tested, the patient is directed to fix it 
upon some distant object. Furthermore, we must test the reaction 
of the pupil to convergence and accommodation. Lastly, we deter- 
mine whether the pupil is circular, of normal width, centrally placed, 
and of pure black hue. 

Of the lens we see under ordinary circumstances only the small 
section of the anterior surface, which lies free in the pupil. If we 
wish to examine the lens more extensively, we dilate the pupil with 
homatropine and use lateral illumination. As long as the lens is still 
transparent, the ophthalmoscope gives us the best conclusions in re- 
gard to its constitution. Whether the lens is present in the eye at 




4 EXAMINATION OF THE BYE. 

all or not can be determined by investigating the Purkinje-Sanson re- 
flex images. If a candle is placed before the eye and somewhat to one 
side of it, two brilliant reflections are observed. One of these at once 
attracts our attention by its size and brilliancy ; it is the corneal reflex 
— that is, the erect image of the flame reflected from the anterior sur- 
face of the cornea (Fig. 1, a). It is this re- 
flex which even from a distance is visible in 
every eye, and gives to the latter its fire and 
luster. The second reflex is quite as bright, 
but so small that we have to search for it in 
order to find it. It presents the very small 
inverted image of the flame which is reflected 
from the posterior surface of thei lens (pos- 
terior lenticular reflex. Fig. 1, c). It is dis- 
tinguished by moving in the contrary sense 
Fig. i.-purkinje-sanson's Re- to the sourcc of light whcn the position of 

FLEX Images. ° ■*■ , 

The black circle represeEts the the latter is shifted ; if the candle IS de- 

S^l^|tS.'Th?c'aa'fltL'I pressed, the shining point rises, and vice 

to^b^ser^i's^'eye^toVeie^^^ ^ersa, in opposition to the Corneal reflex, 

of the pupil, a, image formed which moves in the Same sense as the candle 

by the anterior surface of the 

cornea. 6, image formed by flame. It is this posterior lenticular image 
lens, c, image formed by the that is used in doubtf ul cases to demonstrate 

posterior surface of the lens. r ,i ■, ..i xj!n 

the presence of the lens in the eye. If the 
image is visible, the lens is present ; if the image is not seen, either the 
lens is absent from its place or else is more or less opaque, so that a 
reflection can no longer be developed on its posterior surface. (Fig. 1 
also shows a third reflex image, S, placed between the other two and 
originating from the anterior surface of the lens. The latter gives an 
erect image larger than the others, but so faint that it can be made out 
only with difficulty.) 

Finally, before proceeding to an examination with the ophthalmo- 
scope, the tension of the eye is to be tested. The eye is closed and pal- 
pation is made by means of the two index fingers, which are placed 
upon the upper lid. Here, as in all the previously mentioned methods 
of examination, the best measure for any variation from the normal 
is obtained by a comparison with the other eye, it being presupposed 
that the latter is healthy. 

Examination with the Ophthalmoscope (Ophthalmoscopy). 

2. The invention of the ophthalmoscope by Helmholtz in the year 
1851 was one of the most beneficent achievements in modern medi- 
cine. It has made the interior of the eye accessible to investigation ; 
blood-vessels and nerves, which in the rest of the body are exposed only 
by surgical manipulation, here lie unveiled before us and permit us to 
study their minutest variations. In ophthalmology, the ophthalmo- 



OBJECTIVE EXAMINATION OP THE EYES. 5 

scope has produced a complete revolution, since it has thrown light 
into the dark region of what was formerly called black cataract, and 
has acquainted us with the manifold morbid processes which lie at 
the root of this dreaded malady. Many of these processes, if diagnosti- 
cated correctly and in time, would, at the present day, receive success- 
ful treatment. Furthermore, in general medicine the ophthalmoscope 
has become an indispensable aid to diagnosis, since many internal dis- 
orders produce characteristic changes in the fundus of the eye. 

Principle of the Ophthalmoscope. — In order to see the fundus of 
an eye, we must throw light by the aid of suitable apparatus through 
the pupil and upon the fundus, and receive the light reflected from the 
latter into our own eye and unite the rays to form a sharp image. In 
the original ophthalmoscope of Helmholtz this end was obtained in the 
following way: Before the eye under investigation {A, Pig. 2) a glass 
plate, P F, is placed in an oblique position. A source of light, L, 
placed to one side of the eye, throws upon the glass plate rays, part of 
which are reflected at the surface of the plate and pass through the 
pupil into the eye, A. The rays reflected from the fundus, a, arrive 
once more at the glass plate and are there in part reflected to the 
source of light, L, while another part goes through the glass plate and 




Fio. 2.— Principle of Helmholtz's Ophthalmoscope. 

enters the observer's eye, B, which unites the rays upon its retina into 
a well-defined image, b. In order to increase reflection at the sur- 
face of the plate and thereby illuminate the background of the eye 
more intensely, Helmholtz placed three such plates one behind the 
other. A later modification consisted in increasing the reflecting 
power of the glass plate by lining its posterior surface with a mirror 
coating, a round hole through the plate or at least through the mirror 
coating enabling the observer to see through it. Of this sort are the 
coated plane mirrors, or mirrors of feeble illumination which are now 



6 EXAMINATION OP THE EYE. 

employed. As mirrors of strong illumination we designate concave 
mirrors, which are also coated and are perforated through the center 
(first employed by Euete). These, from the fact that they render con- 
vergent the rays springing from the source of light, throw a still 
greater quantity of light throTigh the pupil into the observed eye. An 
apparatus is placed on the posterior surface of the mirror, which 
renders it possible to bring different sorts of lenses before the aperture. 
In this way it is possible to give the rays of light which fall into the 
observer's eye any path that may be necessary in order to unite them 
into a sharp image upon the retina. 

Method of Examination. — The examination is conducted in a dark- 
ened room. The patient sits opposite the physician, and has on the 
side of the eye to be investigated a lamp as a source of light. Then 
there are two different methods to be employed for seeing clearly the 
fundus of the eye. In order to make the explanation of them simpler, 
we first presuppose that both the patient and the physician have a normal 
refraction (emmetropia, see § 137). In the examination with the erect 
image {direct method), the physician places himself and his mirror 
directly in front of the eye that he is observing. If now he holds the 
mirror obliquely in such a manner that he throws the light of the 
lamp into the pupil of the observed eye, he will immediately get a clear 




Fig. 3.— Ophthalmoscopic Examination with the Erect Image. 
The eyes are drawn ot the natural size of an emmetropic eye having an axial length of 24 mm 
^n^rtKfthlt%'S^?|??ro^LThe*^ltSr ^' ^ ^' ""° '""^ ''^^ ""^'^ ^^« "« ""' ^'>°™ ""* 

view of the patient's fundus. For (Fig. 3) a certain portion of the 
fundus of the eye. A, is illuminated by the mirror, S S. The rays re- 
flected from any point, as a of this illuminated region of the retina, 
leave the eye in a parallel direction, pass through the central aperture 
of the mirror, and fall into the observer's eye, B. Here they are again 
united at a single point, I, upon the retina of this eye, so that here 
there is produced a sharp image of the point a. Since the same pro- 



OBJECTIVE EXAMINATION OP THE BYES. 7 

■cess is repeated for all the other points of the illuminated region of 
the retina of the eye, A, a sharp image of this portion of the retina is 
formed in the eye of the observer. 

The examination with the inverted image, or by means of the in- 
direct method (Euete), is conducted with the aid of a strong convex 
lens of about six cm. focus. This lens, L (Fig. 4), is held at a distance 
of about six cm. from the eye (A) under examination. The fundus of 




Fig. 4. — Ophthalmoscopic Examination with the Inverted Image. 

■The illummation of the fundus is accomplished by means of the source of light, L, from which 
the cone of rays, fc, falls upon the mirror, ,S 5, and from this is thrown into the eye, A. In 
order not to confuse the representation, these rays are not shown, but only those ■which pass 
out of the eye, Ay again. 

this eye is now illuminated by means of the mirror S S. The rays 
reflected from the illuminated region, a, of the retina pass out in a par- 
allel direction, fall upon the lens and are united at the focus,/, of the 
latter. Thus there is formed at this spot an image of the point a. In 
like manner images from the other points of the illuminated region of 
the retina are produced in the focal plane of the lens, so that there is 
formed here an inverted image of this portion of the fundus. The 
observer's eye, £, now through the aperture, 0, of the mirror examines 
this image at the ordinary reading distance (about thirty cm.), for 
which purpose the observer, unless he is myopic, must use a certain 
accommodative effort, or else a corresponding convex glass. 

Each of these two methods has its advantages. The erect image 
is highly magnified — about fourteen times — as opposed to the inverted 
image, which is magnified but little (about four times). The direct 
method is therefore particularly adapted for the recognition of the 
finer details. The indirect method, on the other hand, affords a larger 
field of view, and therefore gives a better general prospect. The indi- 
rect method gives a more luminous image, and hence, when the re- 
fracting media are turbid, will still render the fundus visible when it is 
no longer to be seen in the direct image ; and in myopia of high degree 



8 EXAMINATION OF THE EYE. 

the indirect method is the only one practicable. In most cases, both 
methods are applicable, and then it is advisable to conduct the exam- 
ination with the aid of both. 

Luminosity of the Pupil.— Under ordinary circumstances the pupil ap- 
pears black. This was formerly ascribed to the absorption by the dark back- 
ground of the eye of all the light entering the pupil from the outside. In 
reality, however, the cause of this phenomenon is as follows : If (Fig. 5) light 




Fig. 5,— Path of the Rays when the Eye is focused for the Source of Light. 

from a source of light, L, enters the eye, A, and the latter is accurately focused 
for the source of light, the rays coming from L are united to form a sharp 
image upon the retina at I. L and I are called conjugate foci. For these the 
law holds good that they can be substituted for each other — ^that is, if the rays 
should start from the posterior focus, I, they would come together again at the 
anterior focus, L. Accordingly, the rays reflected from the illuminated portion 
of the retina, I, are returned to the source of light, L, and could be seen by 
an observer only in case the latter was in identically the same spot as the 
source of light. The solution of this problem is another of the ingenious dis- 
coveries of Helmholtz. 

The conditions are different when the eye is not focused for the source of 
light before it. Suppose, for example, that the eye is hypermetropic (Fig. 6). 
Then the rays springing from the illuminated portion of the retina, I, leave 




■Explanation of Luminosity of the Eye. 



The source of light, L, throws the conical beam of rays, fc, into the eye. The further course of 
these rays is not shown in the figure, but only that of the rays reflected from the retina at I. 

the eye as a divergent beam, so that only a part of the rays are returned to 
the source of light, L, while another part passes to the side of the latter and 
can be seen by an observer stationed near it. Hence comes the striking lumi- 
nosity of the pupil in so-called amaurotic cat's eye (see § 99), in which a mark- 
edly hypermetropic condition of the refraction is produced by the pushing 



OBJECTIVE EXAMINATION OP THE EYES. 9 

forward of the retina. In like manner, luminosity is frequently apparent in 
eyes which are deprived of their lens by the operation for cataract and are there- 
fore strongly hypermetropic. Moreover, the enlargement of the pupil, which is 
at the same time present, and which is due to the iridectomy, renders it still 
easier to observe the luminosity. The luminosity of the eyes of many beasts, 
especially the carnivora, is also in part to be ascribed to the hypermetropic 
character of their refraction, although here the presence of a strongly reflect- 
ing layer (the so-called tapetum) in the chorioid of these eyes contributes to 
this result. 

The luminosity of the pupils of albinos' eyes is to be explained in a differ- 
ent way. In such eyes the light passes not only through the pupil, but also 
through the unpigmented iris, and ev.en through the sclera. Accordingly, in 
these eyes, not simply a limited district of the retina, but the whole fundus, 
is flooded with diffused light ; and therefore rays from the different portions 
of the fundus pass out of the pupil in every direction and can very readily be 
caught up by the observer's eye. That this explanation is the correct one is 
proved by the fact that the pupil of an albino's eye looks black as soon as we 
hold before the eye a screen having an aperture that corresponds in size to the 
pupil. This shuts off from the eye any light which might enter it through 
other media than the pupil, and in this respect makes the eye of an albino 
like that of a normal person. 

3. Application of the Ophthalmoscope.— In the ophthalmoscopic 
examination of the eye we invariably proceed by carefully investigating 
the eye by means of lateral illumination first, next testing the trans- 
parency of the refracting media with the ophthalmoscope, and not 
going on to the examination of the fundus itself until last of all. This 
last examination is best made first with the inverted, afterward with 
the erect image ; and in examining the latter the refraction can be de- 
termined at the same time. If the pupil is narrow, the tyro will do 
well to dilate it with cocaine or homatropine. Before doing so he 
must make sure that there is no reason to suspect glaucoma, in which 
case artificial dilatation of the pupil might have dangerous results, and 
therefore must not be employed. 

For testing the transparency of the refracting media light is thrown 
by the ophthalmoscope, held at the ordinary reading distance, into the 
eye under examination. If the refracting media are perfectly clear, 
the pupil shines with a uniform red luster. If there are places in the 
refracting media that are opaque, such stand out upon the red back- 
ground of the illuminated pupil as dark points or spots. For example, 
the rays which correspond to the opaque spot t (Fig. 7) are cut off on 
their return from the fundus, a, so that this spot is not illuminated 
and hence looks black. This is the case even when the opacities are 
actually, as seen by light thrown directly upon them, light colored— 
that is, white or gray. So also even a piece of chalk looks black if it 
is held in front of a flame. 

In making a systematic examination of the fundus we begin at the 
papilla. In order to bring the latter into view at once, we make the 



10 EXAMINATION OP THE EYE. 

patient look, not straight in front of him, but a little inward (toward 
his nose). For the entrance of the optic nerve does not lie at the 
posterior pole of the eye, but on the nasal side of it, and hence is 




Fig. 7, — Visibility of Opacities in the Media by Means op the Ophthalmoscope. 

brought directly opposite the observer only after a corresponding rota- 
tion of the eye inward. It then comes into view as a bright disk, 
whose color is a light grayish or yellowish red, contrasting strangely 
with the red of the rest of the fundus (Fig. 8). The shape of the 
papilla is circular or oval ; in the latter case generally an erect oval. Its 
size apparently varies quite a good deal, which, however, is due to the 
varying degree of enlargement under which the papilla is seen. The 
true size of the papilla, measured in enucleated eyes, is, as a matter of 
fact, almost always the same — that is, about 1.5 mm. in diameter. On 
account of this constancy we use the papilla for taking measurements 
in the fundus ; we say, for example, that a diseased area is 2 papilla- 
breadths in diameter. 

Circumscribing the papilla, we very often (especially in making the 
examination with the erect image) recognize two rings distinct in color. 
The inner ring, lying next the border of the papilla, is white (Fig. 9 
A between c and d; see also Pigs. 8 and 11), and is called the scleral 
ring, because it owes its white color to the fact that the sclera is here 
exposed to view. It is present when the canal in the sclera, through 
which the optic nerve passes, is narrowest, not as is often the case, at 
its anterior orifice, but somewhat farther back, so that the foremost 
portion of the canal forms a funnel with the base forward. The wall 
of this funnel, which is formed of white sclera (Fig. 9 £ between c and 
d), appears when seen with the ophthalmoscope in perspective foreshort- 
ening, as a narrow white ring. At the margin of the aperture in the 
chorioid that gives passage to the optic nerve, the chorioid is often 
marked by a larger accumulation of pigment, by which the second, ex- 
terior ring is formed. This is apparent as a black, narrow, sometimes 
complete, sometimes incomplete, ring, which is designated as the 
chorioidal ring or pigment ring (Fig. 9, d, and Fig. 8, where it is visi- 
ble especially at the outer border of the papilla). 



OBJECTIVE EXAMINATION OF THE EYES. 



11 



The demarcation of the outline of the papilla, produced in this 
way, is generally much less sharp on the nasal than on the temporal 
side ; for at the nasal side a greater number of nerve fibers pass over 
the margin of the papilla and thus obscure it. For the same reason 
the inner half of the papilla looks redder, the outer half paler, because 
the layer of nerve fibers in the latter situation being thinner, allows 
the lamina cribrosa to show through more. 

The optic disk under normal conditions lies in the plane of the 
retina, and does not therefore form a projection upon it as the name 
papilla would lead one to suppose. On the contrary, it very frequently 
contains in its center a depression, which is produced by the fibers of 
the optic nerve separating from each other comparatively early and 
thus leaving a funnel-shaped' space between them (vascular funnel, 



natal 




^^1 f temporal 



Fig. 8. — Normal Fundus of the Left Eye, seen in the Erect Image. 

The optic disk, which is somewhat oval longitudinally, has the point of entrance of the central 
vessels somewhat to the inner side of its center. That portion of the papilla lying to the 
inner side of the point of entrance of the vessels is of darker hue than the outer portion ; 
the latter shows, directly to the outside of the vascular entrance, a spot of lighter color, the 
physiological excavation with fine grayish stippling, representing the lacunae of the lamina 
cribrosa. The papilla is surrounded, first by a light-colored ring, the scleral ring, and exter- 
nally to this by an irregular black stripe, the chorioidal ring, which is especially well marked 
on the temporal side. The central artery and vein divide immediately after their entrance 
into the eye into an ascending and descending branch. These branches, while still on the 
papilla, split into a number of smaller divisions, and fine offshoots from them run from all 
directions toward the macula lutea, which itself is devoid of vessels, and is distinguished by 
its darker color. In its center a bright punctate reflex, /, is visible. 

Pig. 9 B, I). The central vessels ascend on the inner wall of the fun- 
nel. The color of the vascular funnel seems white to us because we see 
the white lamina cribrosa at its bottom. Often, instead of a small 
funnel-shaped depression, a large excavation {physiological excavation) 
is present. This is situated in the outer half of the papilla, to whose 
external border it often reaches. The blood-vessels come out upon the 
inner border of the excavation (Pig. 8), and at the bottom of the latter 
are seen grayish dots, the lacunse of the lamina cribrosa. With the 
brilliant white of the excavated exterior half of the papilla the grayish- 



12 EXAMINATION OP THE EYE. 

red hue of the unexcavated interior half is in vivid contrast. Some- 
times the physiological excavation is so large that it takes in the larger 




B 

Fig. 9.— Head of the Optic Nerve. 

A^ Ophthalmoscopic View.— Somewhat to the inner side of the center of the papilla the cen- 
tral artery rises from below, and to the temporal side of it rises the central vein. To the 
temporal side of the latter lies the small physiological excavation with the gray stippling of 
the lamina cribrosa. The papilla is tncircled by tne light scleral ring (between c and d), and 
the dark chorioidal ring at d. 

B, Longitudinal Section through the Head op the Optic Nerve.— Magnified 14 x 1. The 
trunk of the nerve up to the lamina cribrosa consists of meduUated nerve fibers, n. The 
clear interspaces, se, separating them, correspond to the septa composed of connective 
tissue. The nerve trunk is enveloped by the sheath of pia mater, p, the arachnoid sheath, 
m\ and the sheath of dura mater, du. There is a free interspace remaining between the 
sheaths, consisting of the subdural space, sd^ and the subarachnoid space, sa. Both spaces 
have a blind ending in the sclera at e. The sheath of dura mater passes into the external 
layers, sa, of the sclera, the sheath of pia mater into the internal layers, si, which latter 
extend as the lamina cribrosa transversely across the course of the optic nerve. The nerve 
is represented in front of the lamina as of light color, because here it consists of non-medul- 
lated and hence transparent nerve fibers. The optic nerve spreads out upon the retina, r, 
in such a way that in its center there is produced a funnel-shaped depression, the vascular 
funnel, 6, on whose inner wall the central artery, a, and the central vein, v, ascend. The 
chorioid. c7i, shows a transverse section of its numerous blood-vessels, and toward the retina 
a dark line, the pigment epithelium ; next the margin of the foramen for the optic nerve 
and corresponding to the situation of the chorioidal ring, the chorioid is more darkly pig- 
mented, ci is a posterior short ciliary artery which reaches the chorioid through the sclera. 
The posterior portion of the scleral canal forms a funnel directed backward, the anterior 
portion a funnel directed forward. The wall of the anterior funnel when seen from in front 
appears to have the extent, cd, and corresponds to the scleral ring visible by the ophthal- 
moscope. 

part of the papilla, but it never takes in the whole ; there is always a 
part (though it may be a small part) of the papilla that escapes it. By 
this circumstance the physiological is distinguished from the pathologi- 



OBJECTIVE EXAMINATION OP THE EYES. I3 

cal excavation, which affects the entire papilla (total excavation, 
cf. § 81). 

The central vessels of the optic nerve divide at the head of the 
nerve into a number of larger and smaller branches, which pass over its 
edge into the retina, where they keep on branching after the fashion 
of a tree trunk. They can readily be distinguished into arteries and 
veins. The former are of a brighter red, narrower, and run a straight 
course (Figs. 8 and 9, a a) ; the latter are darker, of greater caliber, 
and more crooked (Figs. 8 and 9, v v). The arrangement of the vessels 
in the retina is not always the same ; most frequently it happens that 
two main branches run upward and two downward, while only small 
and short twigs pass to the outer and inner sides of the disk (Fig. 8). 
The region of the macula lutea is devoid of larger vessels ; the larger 
trunks, running to the outside above and below, encircle it and send 
finer branches in toward it. 

In the larger vessels we notice a shining white streak running along 
the center of the vessels. This streak, which is more distinctly visible 
in the arteries (Fig. 9 A, a a) than in the veins {v v), is called the 
reflex streak (Jager). 

A pulsation is frequently observed in the vessels at the spot where 
they first come to view upon the papilla. A venous pulse is a physio- 
logical occurrence : in the same eye it is sometimes present, sometimes 
absent. In the latter case, slight pressure upon the eye with the finger 
suffices to produce it. 

Bonders gives the following explanation of the venous pulse : At 
each systole of the heart an additional quantity of blood is driven into 
the arteries of the interior of the eye, and the blood pressure in these 
arteries is consequently heightened. This increase in the arterial ten- 
sion reacts at once upon the general intra-ocular tension, heightening 
the latter, so that it acts more vigorously upon the retinal veins and 
compresses them. It does this most at the spot where the blood pres- 
sure in the veins is lowest, which is at their point of emergence upon 
the papilla, since the blood pressure in the veins diminishes in propor- 
tion as we approach the heart and get farther away from the capillaries. 
The veins consequently are constricted at the spot where they dip down 
into the vascular funnel, while the portion of the veins directly ad- 
jacent swells up, because the blood is dammed up in it. But as a 
result of this damming, the blood pressure in the veins rises rapidly to 
the point where it is able to overcome the compression— doing this the 
more readily as now the diastole of the heart sets in, and with this the 
intra-ocular pressure diminishes. 

An arterial pulse is present under pathological conditions only. 
In order to produce it artificially in a healthy eye, no inconsiderable 
pressure must be exerted upon the eyeball. When this is done, the 
person under examination notices a simultaneous obscuration of the 



14 EXAMINATION OF THE EYE. 

field of vision, amounting finally to complete abrogation of sight, as a 
result of the obstruction to the retinal circulation produced by the 
pressure. In like manner a rise in pressure produced by pathological 
conditions (glaucoma) causes an arterial pulsation. The explanation of 
this is as follows : As a result of the increased pressure in the interior 
of the eye, the blood is able to enter the vessels of the retina only dur- 
ing the systole of the heart ; during the diastole, when the pressure in 
the arteries becomes somewhat lower, the latter are occluded by the 
intra-ocular pressure. Such a disproportion between the intra-ocular 
pressure and the pressure of the blood in the central artery may also, 
of course, be produced by the fact that while the former remains nor- 
mal, the latter is diminished. Accordingly, an arterial pulsation is 
observed in general anaemia and when syncope is imminent ; also in 
local compression of the central artery within the optic nerve (e. g., in 
optic neuritis). Lastly, in some cases — e. g., in insufficiency of the 
aortic valves and in Basedow's disease — the presence of an arterial pulse 
in the eye is but one of the symptoms of an abnormally extended dif- 
fusion of the pulse wave in all parts of the body. 

Since in healthy living eyes the retina is transparent, we see no 
part of it with the ophthalmoscope except the blood-vessels. At most 
we find the red fundus in the immediate neighborhood of the papilla 
covered by a delicate gray veil which shows a radiating fine striation 
and which is the representative of the layer of nerve fibers of the 
retina, which in this situation is still quite pronounced. In children 
vivid reflexes often exist which are especially pronounced along the 
vessels, change their place with every movement of the mirror, and 
give the retina a luster like that of watered silk. We must avoid re- 
garding these as pathological opacities of the retina. The region of 
the retina that is most important for vision, the macula lutea, with 
the fovea centralis, is Just the part that has very few distinctive 
ophthalmoscopic features. We find it with the ophthalmoscope, if we 
go a distance of 1| to 3 diameters of the papilla outward from the 
outer border of the papilla. Here we come upon a region devoid of 
vessels which is somewhat darker than the rest of the fundus. Di- 
rectly in its center, corresponding to the situation of the fovea cen- 
tralis, we see a bright point or a small, crescentic spot (Pig. 8, /). 
In the inverted image the macula lutea is represented by a fine white 
line which forms a horizontal oval of about the size of the papilla. 
The region inclosed by the line is colored a dark brownish red and 
sometimes has in its center a little bright dot. These appearances 
are nothing more than reflexes produced by the light on the inner 
surface of the retina, and are by no means constantly present. When 
the pupil is dilated they become less marked or disappear altogether. 

The red background on which the appearances above described 
are visible is made by the chorioid. This owes its red color to the 



OBJECTIVE EXAMINATION OP THE EYES. 15 

blood circulating in the chorioidal vessels, and especially in the capil- 
laries. That the individual vessels are not themselves recognized, 
that on the contrary the fundus appears uniformly red, is due to the 
fact that the pigment epithelium covers the chorioid like a murky veil. 
The pigment epithelium, too, has a marked effect upon the brightness 
of the red color of the fundus. In very dark-hued men the pigment 
epithelium scarcely allows the red of the chorioid to shine through, so 
that the fundus appears almost dark gray. The less pigmented the 
person is, the brighter the red of the fundus. In such cases a finely 




Fie. 10.— Tessellated Fundus. 

(For the alteration of the papilla here depicted, which is due to congenital malformation, see 
the description attached to Fig. 111.) 

granular condition of the chorioid is often perceived in the erect 
image, which is caused by the cells of the pigment epithelium. 

Under certain circumstances, however, the vessels also of the chori- 
oid are visible. We observe this chiefly under two conditions, viz. : 

(1) In many eyes the interspaces between the chorioidal vessels 
(the so-called intervascular spaces) have an especially profuse pigmen- 
tation, so that they stand out as dark elongated islands ; the bright-red 
striae running between them and anastomosing everywhere with each 
other, correspond to the chorioidal vessels which are chiefly veins. 
Such a fundus is said to be tessellated (Pig. 10) ;, it is often confounded 
with chorioiditis by beginners. 

(3) In other eyes, on the contrary, it is the abnormally scanty 
pigmentation of the fundus that permits the vascular system of the 
chorioid to be seen; the epithelial layer, on account of the unduly 



16 EXAMINATION OF THE BYE. 

small amount of pigment which it contains, allowing the chorioidal 
vessels to appear through it. This is in the greatest degree the case in 
albinos, who are entirely devoid of pigment. In these the whole net- 
work of chorioidal vessels down to the most delicate ramification stands 




Fig. 11.— FnNDUB of as Albinotio Ete seen in the Erect Image. (After Jager.) 

The papilla Ls surrounded by a light-colored scleral ring, and looks dark in comparison with the 
light hue of the rest of the fundus. The latter shows a thick network of chorioidal vessels 
and over them the retinal vessels, which are distinguished from the former by their better 
defined outline, their narrow caliber, and their tortuous course. Both the chorioidal and 
retinal vessels contrast by their darker red with the very light red of the background, the 
line of which is formed by the white sclera shining through the chorio-capillaris. It is only 
at the macula hitea that the somewhat darker hue of the fundus gives evidence of the 
presence of a slight pigmentation of the chorioid. 

out upon the pale-red background (Fig. 11). The retinal vessels run 
over the chorioidal vessels, but are easy to distinguish from them. 
The chorioidal vessels are broader, less sharply defined, and look flat 
and ribbonlike; they lack the reflex streak. In opposition to the 
retinal vessels, which branch after the manner of a tree and do not 
anastomose, they form by their numerous anastomoses a dense network 
with elongated meshes. 

Examination of the Kepr acting Media. — For this purpose, when pro- 
nounced opacities are present, we make use of the concave mirror ; slight 
opacities, on the other hand, are discovered only by means of the mirror of 
feeble illumination (plane mirror) ; and in this case it is often also necessary to 
dilate the pupil with homatropine. If the observer is emmetropic, and still 
more if he is hypermetropic, he ought to place a convex glass behind his 
mirror, so as to be able to get near enough to the eye that he is examining and 
still see with distinctness. A myopic observer will not need such a glass. In 
examining, we must not neglect to make the eye move in different directions, in 
order, on the one hand, to obtain a view of laterally placed opacities, and, on 



OBJECTIVE EXAMINATION OF THE EYES. 17 

the other hand, to stir up in this way opacities which have sunk to the bottom 
of the vitreous humor. Smaller opacities look black ; larger opacities appear 
gray or even white, since the light reilected from their surface is strong enough 
to shine out upon the vivid red background of the illuminated pupil. In order 
to recognize the site of the opacity, we decide, in the first place, whether the 
latter is movable or fixed. In the former case it can be situated only in the 
vitreous; in the latter case— that is, if the opacity moves only with the eye, 
and not spontaneously — it is probably situated in the cornea or in the lens; but 
it may still be in the vitreous, since here too fixed opacities are sometimes 
observed. In many cases this can be decided by employing lateral illumina- 
tion. If we can obtain no result in this way, we then, in order to determine 
the site of the opacity, make use of the iiamllactic d splacement of the latter 
with reference to the margin of the pupil. 'J'his is accomplished in the follow- 
ing way: In the e^-e, A (Fig. 12), suppose four opaque points to be present, 
which lie at different depths — namely, in the cornea (1), upon the anterior cap- 
sule of the lens (2), at the posterior pole of the lens (3), and in the anterior 
part of the vitreous (4). For simplicity's sake we assume that they are all dis- 
posed in the optical axis of the eye. Then, if the observer, B, looks into the 
eye from directly in front, he will see each one of these points precisely in the 
center of the pupil, P. Suppose, now, that the observer's eye passes from B to 
Bi. The position of the points with relation to the jiupil will be changed at 
once. Point 1 approximates to the upper border of the pupil P, ; point 2, 
which is situated in the pupil itself, keeps its place unchanged ; points 3 and 4 
have approached the lower border of the pupil ; and 4, on account of its greater 




Fig. 18.— Diagnosis of the Site of an Opacity from Parallactic Displacement. 

depth in the eye, more so than 3. From this example the following rule for 
the determination of the site of an opacity can be deduced : We look into the 
eye from directly in front and note the position of the opacity in the pupil. 
Then, while the patient holds his eye fixed, we move slowly to one side and 
observe whether the opacity remains in the same spot or not. In the former 
case, the opacity lies in the pupillary plane (upon or directly beneath the 
anterior capsule of the lens) ; in the latter case, in front of or behind this plane 
—in front of it, if the opacity shifts its place with a movement opposed to that 
2 



18 EXAMINATION OF THE EYE. 

of the investigating eye ; behind it, if the opacity moves in the same sense as 
the eye. The more quickly this change of place occurs, the farther removed is 
the opacity from the pupillary plane. (Evidently we can also proceed by keep- 
ing our own eye still and telling the patient to move his. This way of exam- 
ining has the disadvantage that, if the movement of the observed eye is rather 
extensive, a minute opacity, whose position has been marked, may disappear 
out of sight and then frequently is found again only with difficulty.) 

Dark, ill-defined shadows on the red background of the pupil, which change 
their position suddenly on moving the mirror, are to be referred to irregulari- 
ties of the refracting surfaces (most frequently to faceting of the cornea) ; the 
irregular astigmatism so caused further betrays itself by the fact that the image 
of the fundus appears irregularly distorted. 

Determination of the Refraction.' — The determination of the refrac- 
tion by the ophthalmoscope may be accomplished in three ways : with the erect 
image, with the inverted image, and by the shadow test. 

(1) Determination of the refraction with the erect image. When the eye 
under examination is emmetropic, the rays emitted from the illuminated retina 
emerge parallel to each other (as shown in Fig. 3) ; hence the observer's eye, 
which in all that follows we shall assume to be emmetropic, can without exer- 
cising any accommodation unite them into a sharp image. Emmetropia, how- 
ever, represents the only condition of the patient's eye in which an emmetropic 
observer can without ulterior aid see distinctly the patient's fundus ; when the 
patient's refraction is of any other nature, the observer, to see clearly, must use 
either a glass or his accommodation. 

Suppose the eye to be examined {A, Fig. 13) to be myopic, with its far point 
at F so that the rays coming from i?" are united on the retina aty (see § 143). 




FiQ. 13.— Correction of Myopia by a Concave Lens. 
The eye is drawn of the natural size of a myopic eye having an axial length of 27 mm. 

FmA/are conjugate foci, and the course of the rays would therefore be the same 
if they should proceed in the opposite direction— i. e., from /toward F; in that 
case, they would be united at F, as they emerge from the eye. A point/ of the 
retina, illuminated by the ophthalmoscope, will then emit a bundle of rays con- 
verging at F; and at this distance there is produced a clear image of the illu- 
minated fundus. The observer's eye, which is placed at a short distance (a few 
centimetres) from the eye A, would catch the rays emitted from the latter 
before they were united at -f— that is, while they still had a certain amount of 



OBJECTIVE EXAMINATION OP THE EYES. 19 

convergence. But the observer's eye, unless it were hypermetropic, is not in a 
position to unite convergent rays into a sharp image. If the eye is emmetropic, 
as we will assume it to be, the rays which fall upon it must first be made par- 
allel, which evidently is accomplished by a concave lens, L. Now, how is this 
lens related to the degree of myopia of the eye under investigation ? If we im- 
agine the course of the rays reversed, then parallel rays coming from in front and 
falling upon the lens L would be rendered by the latter so divergent that they 
would come to a focus upon the retina of the myopic eye; the myopic eye 




Fig. 14. — Correction op Hypebmetropia by a Convex Lens. 
The eye is drawn of the natural size of a hypermetropic eye having an axial length of 21 mm. 

accordingly would get sharp vision with this lens for parallel rays — that is, rays 
coming from an infinite distance. L would therefore be the correcting glass for 
the myopia of the eye, A. We can hence say this : In order that an emmetro- 
pic observer should see clearly the fundus of the myopic eye, A, he must use 
the same glass that will correct the myopia of this eye. If, therefore, an em- 
metropic observer has to determine the refraction of a myopic eye with the 
ophthalmoscope, he keeps placing concave glasses before it until he finds one 
with which he gets a sharp view of the fundus in the erect image ; the glass 
employed gives directly the degree of the myopia. The same principle holds 
good for hypermetropic eyes, only that convex instead of concave glasses are 
required. The rays emitted "from the hypermetropic eye, A (Fig. 14), are 
divergent, and the more so the higher the hypermetropia is. The convex glass, 
X, which is required in a given case of hypermetropia in order to render par- 
allel the divergent rays emerging from the eye and thus make it possible for 
the emmetropic observer to perceive the fundus, is the same as that which ren- 
ders rays falling upon the eye in a parallel direction so convergent that they 
are united upon the retina, and is therefore the glass which corrects the hyper- 
metropia. Hence the degree of hypermetropia of the eye under examination is 
given immediately by the convex lens with which the emmetropic observer sees 
the fundus distinctly. 

An emmetropic observer can also, it must be noted, cause divergent rays to 
focus upon his retina by calling his accommodation into play, and in this way 
can see the fundus of a hypermetropic eye distinctly even without the aid of 
a convex glass. But as one can not estimate precisely the degree of accommo- 
dation thus applied, it is impossible to determine the amount of hypermetropia 
with precision by proceeding in this way. 

How is it in those cases in which the physician himself is not emmetropic ? 



20 EXAMINATION' OF THE BYE. 

In that case he must simply correct in addition his own ametropia ? If, for 
instance, an emmetrope is examining an eye having a myopia of 3 D, he needs 
for this purpose — 2D. If the observer himself should have a myopia of 3 D, 
he would have to take in addition — 3 D for himself ; hence he would employ 
a glass of — 5 D. If the observer were a hypermetrope of 1 D, he would need 
+ 1 D for the correction of his own ametropia ; this, in combination with the 
— 2D which are required for the eye under examination, gives a lens of — 1 D. 
A similar procedure must be adopted in those frequently occurring cases in 
which the observer is indeed emmetropic, but can not completely relax his 
accommodation during the ophthalmoscopic examination. He is then to be 
regarded as a myope, inasmuch as he has to neutralize his residual accommo- 
dation by a corresponding concave glass. 

(2) The determination of the refraction with the aid of the inverted image is 
done by the method proposed by Schmidt-Rimpler, the principle of which is 
as follows : The concave mirror, 8 S (Fig. 4), forms at its focus a sharp image 
of the flame that is used as the source of light in making the ophthalmo- 
scopic examination. This image lies between the mirror and the convex lens 
(I). Rays emanating from it are by means of the lens thrown upon the retina 
of the patient's eye to form there a new image of the flame, which the observer 
sees upon the fundus. Whether this latter image is sharp or not depends 
upon various circumstances : upon the strength of the mirror and the lens; 
upon the distances between the lamp, the mirror, the lens, and the eye ; and 
lastly upon the refraction of the latter. By taking all these factors into con- 
sideration we can determine the refraction, provided we ascertain the distance 
at which the observer has to be in order to see the image of the flame upon the 
fundus of the patient's eye distinctly. For this purpose the apparatus devised 
by Schmidt-Rimpler is employed. 

(8) The determination of the refraction by means of the shadow test was 
discovered by Cuignet, who called it keratoscopy. It is also knovm as pupil- 
loscopy, retinoscopy, and skiascopy (o-Km, shadow). In using it, the observer 
places himself at a distance of rather more than one metre from the patient, and 
throws light into his pupil by means of a concave mirror. When the mirror is 
in a certain position, the whole pupil appears of a vivid red ; then if the mirror 
is turned a little on its vertical axis, a black shadow appears at the edge of the 
pupil and, as the mirror is rotated still more, passes over the whole area of the 
pupil, until the latter is completely dark. From the direction in which the 
shadow travels the refractive state of the eye under examination can be ascer- 
tained. To accomplish this, we must, to start with, have a clear comprehen- 
sion of the signiflcance of the illuminated portion of the pupil and of the 
shadow respectively. 

By means of the mirror a point of the fundus is illuminated, and from this 
point the rays are returned in such a way that a portion of them pass out again 
through the pupil. The direction which these rays take on emerging is deter- 
mined by the refraction of the eye. If myopia is present, we know that the 
emergent rays will converge so as to meet at the far point of the eye. In Fig. 
15 let J P and Pi /, be the iris, and P P, the pupil of the patient's eye. The 
rays emerging from the pupil unite at the far point R of the eye. If we 
suppose that by means of the mirror a point of the retina is illuminated which 
lies somewhat to the right of the line connecting the pupillary centers of the 
observer's and of the patient's eyes, R will be situated correspondingly far to 



OBJECTIVE EXAMINATION OP THE EYES. 



21 



the left of this line. From S the rays (now become divergent) continue on 
their way toward the observer's eye, which we will now suppose to be beyond 
JR. i p and pi ii represent the iris, and p pi the pupil of this eye. Now p pi does 
not take in all of the conical sheaf of rays emanating from M, but only a por- 
tion of it, having ^ o as its base. The remainder of the cone falls upon the 
iris p i. Since the rays constituting this part of the cone are not seen by the 
observer, the portion of the pupil which 
is opposite to them, and from which 
they come (represented in Pig. 15 by 
the lines of shading), appears unillu- 
minated; the only portion of the pupil 
that does appear illuminated being that 
which is here shown as unshaded, and 
from which the observer receives rays 
that enter his own pupil. The dark 
and the luminous portions of the pa- 
tient's pupil are separated by a curved 
line, since the boundary between the 
two is formed by the pupillary edge p 
of the observer's eye. Thus the circle 
at the bottom of Pig. 15 represents the 
pupil of the patient's eye seen from in 
front ; the portion of it left unshaded 
in the figure corresponds to the illumi- 
nated part of the pupil. 

Now suppose that by a rotation of 
the mirror the spot of illumination in 
the fundus shifts in such a way that R 
travels farther to the left. Then more 
and more of the emergent beam will 
fall upon the iris, and less and less of 
it will fall upon the pupil of the ob- 
server's eye, and the shadow in the 
pupil of the patient's eye will, as the 
arrow in the circle indicates, advance 
farther and farther toward the left pu- 
pillary margin, until finally the whole 
pupil appears dark. The shadow, 
therefore, moves in the same direction 
that B does. 

We have now to determine how the movements of R are related to the 
movements of the mirror. If a concave mirror is employed, it forms at its 
focus an image of the lamp flame which lies between the mirror and the pa- 
tient's eye and serves to illuminate the latter. If the mirror is rotated to the 
left, the image of the flame also travels to the left. But as the portion of 
retina illuminated must always lie on the side diametrically opposite to the 
body that illuminates it — namely, the image of the flame — it must, with the 
movements of the mirror, move in a sense opposed to that of the image of the 
flame— i. e., to the right (from B or Bi in Fig. 15). But the point of union, R, 
of the emergent rays lies diametrically opposite to that occupied by the illumi- 




FlG. 15. 



-Shadow Test in Myopia. 



22 



EXAMINATION OP THE EYE. 



nated portion of the retina ; hence R will move to the left— i. e., in the same 
direction as the mirror. Now since B moves to the left when the mirror is ro- 
tated to the left, and as the shadow in 
the pupil travels to the left when B, moves 
to the left, we may say. 

When a concave mirror is used the shadow 
in the patiemfs pupil moves in the same sense 
as that in which the mirror rotates, provided 
the far point of the patienfs eye lies ietween 
the ohserver''s eye and the mirror. 

These relations are reversed when we 
come to examine a myopic eye whose far 
point is beyond the observer's eye. By 
constructing Fig. 15 so that R lies beyond 
i p, it will be found that in this case the 
illuminated portion of the pupil lies on the 
right side, and that as R shifts to the left 
the shadow goes to the right. The like 
is true for those cases in which the far 
point of the patient's eye lies behind the 
latter, as is the case in hypermetropia. 
This will be clear from Fig. 16. P Pi 
represents the pupil of a hypermetropic 
eye, from which the rays that emanate 
from the retina pass out, taking a diverg- 
ent course. They thus form a cone whose 
apex lies behind the eye at its far point, 
R. If the illuminated portion of the reti- 
na lies to the right of the line connecting 
the pupillary centers of the two eyes, E is 
also foimd to the right of the latter. The 
pupil, p pi of the observer's eye takes in 
only that part of the >conical sheaf of rays 
which corresponds to the right-hand por- 
tion of the patient's pupil (the portion left 
unshaded in the figure). The left-hand 
portion of the patient's pupil (represented 
by the lines of shading in the figure) re- 
mains unilluminated, because the rays that 
come out from it no longer fall upon the 
observer's pupil. The more R moves to 
the right, the more the unilluminated 
portion of the pupil is displaced to the 
right in the direction indicated by the arrow in the circle below. The shadow 
therefore, travels in the same direction that R does, as is also the case in myo- 
pia when the far point lies in front of the observer's eye (Fig. 15). The difier- 
ence between the two cases lies in the different relation that the movement of 
R has to the rotation of the mirror. If the concave mirror is rotated to the 
left, the image of the flame produced by it travels likewise to the left, and the 
spot of illumination upon the retina travels to the right (from B to Bi), Then 




i 

Fig. 16.— Shadow Test in Hypermetropia. 



OBJECTIVE EXAMINATION OF THE EYES. 23 

the beam of rays retm-ning from this spot of illumination shifts to the left, but 
B, since in the hypermetropic eye it lies at the prolongation of these rays back- 
ward, moves to the right. B, therefore, moves in a direction opposite to that 
in which the mirror rotates, and the same is true of the pupillary shadow, which 
always moves in the same way that B does. 

Hence when a concave mirror is used, the shadow moves in a direction opposite 
to that in which the mirror is rotated, provided the far point of the patient's eye lies 
behind the observer's eye {in low degrees of myopia) or behind the patient's eye {in 
hypermetropid) . 

The way in which the shadow moves, therefore, depends upon the relative 
situation of the far point and the observer's eye. If the observer stations him- 
self at a distance of rather more than 1 m. (say 130 cm.) from the patient's eye, 
B lies between the two eyes when there is myopia of 1 D. or more, because then 
the patient's far point lies at 1 m. or less from his eye. In myopia amounting 
to less than 1 D. the far point lies behind the observer's eye, and the same is 
true of emmetropia, in which the far point lies at infinite distance. In hyper- 
metropia, on the other hand, the far point lies behind the patient's eye. From 
these facts are derived the following rules for conducting the shadow test : 

The observer, standing at rather more than 1 m. from the patient, illumi- 
nates the eye with a concave mirror, and notices the way in which the shadow 
moves in the patient's pupil as the mirror is rotated. If the shadow moves in 
the same direction that the mirror rotates, there is myopia of 1 D. or more. 
Then successively stronger concave glasses are set before the patient's eye in a 
trial frame * until a glass is found with which the shadow travels in the reverse 
direction. This glass carries the far point of the eye to just beyond 1 m. (cor- 
responding to a refractive power of 1 D.) ; and the last glass, n D., with which the 
shadow still moves in the same sense as the mirror, corrects the myopia of the 
patient's eye up to approximately 1 D. Hence the total myopia of this eye is 
7iD-f-lD. 

If, when the mirror is rotated, a movement of the shadow takes place in the 
opposite direction, there is then in the eye that is being examined either myopia 
less than 1 D. , or emmetropia or hypermetropia. In this case a series of con- 
vex glasses is placed before the patient's eye until the shadow begins to move 
in the same direction as the mirror. If this glass is to D., the refraction of the 
patient's eye is w D — 1 D.^ 

The shadow test can also be conducted with the plane mirror. With this 
the image of the flame lies behind the mirror, and hence, when the latter is 
rotated, moves, not with the mirror, as is the case when this is concave, but in 
the opposite direction. Accordingly, the movement of the pupillary shadow 
with relation to the rotation of the mirror is just the reverse of that which 
obtains with the concave mirror.f 

* [Instead of placing a number of glasses one after another in a trial frame, we 
may also employ a revolving disk, a set of lorgnette frames, or an oblong slide in 
which a series of such glasses is permanently fixed after the fashion of an ophthal- 
moscope. Such an appliance, which is called a sTciascope, allows the glasses before 
the patient's eye to be rapidly shifted either by the patient himself or by the physi- 
cian, without the latter having to move from his station. — D.] 

f [I. e., the shadow moves in the opposite direction to that in which the mirror 
is rotated — moves to the right when the mirror is rotated to the left, or, as the 
phrase is, moves " against " the mirror in myopia of such a degree that the 



24 EXAMINATION OP THE BYE. 

In either case this method is of great simplicity; of all methods it is the 
easiest to leam, and has the advantage that in it the refraction and accommoda- 
tion of the observer do not need to be considered. Withal it gives as exact 
results as any one of the other methods. 

A superficial estim-^te of the refraction of an eye can be got whenever an 
observer at some distance (say about the ordinary reading distance) from it is 
able to see portions of the fundus. This is the case both in marked myopia 
and in marked hypermetropia. In marked myopia the rays emanating from 
the eye come together in front of and very close to it at its focus F (Fig. 13), 
where, accordingly, an inverted image of the fundus is produced, and that 
without the aid of a convex glass. The observer can see this image if he 
places himself at a suitable distance— e. g., the ordinary reading distance. 
That it is an inverted image which he sees is obvious from the fact that it 
moves to the right when he moves his head and mirror to the left, and vice 
versa.* If the observer approaches the patient's eye, the image of the fundus 
rapidly becomes iBdistinct and soon disappears altogether, because the observer 
then gets so close to it that he can no longer accommodate for it. 

In marked hypermetropia, too, the image of the fundus can be seen at 
some distance from the eye, but in this case it is an erect image. It moves in 
the same direction that the observer moves, and remains distinct when the 
latter approaches the patient's eye. We can thus determine whether we are 
dealing with a high degree of myopia or of hypermetropia. 

The presence of regular astigmatism may be recognized from the change of 
shape which the papilla undergoes. In regular astigmatism one meridian of 
the dioptric system of the eye is more refractive than the one at right angles to 
it ; may be said, in fact, to correspond to a stronger convex lens than does the 
latter. Hence with the erect image the papilla will be seen under a greater 
enlargement in the more refractive meridian. If the latter, as is generally the 
case, is vertical, a round papilla will appear like a vertical oval. But the 
papilla often has in reality an oval form ; and, in order to distinguish whether 
we are dealing with a papilla that is anatomically oval or with an astigmatic 
distortion of a round papilla, we must resort to a comparison with the inverted 
image. If the papilla is really a vertical oval, it must appear so with the in- 
verted image also. If, however, there is astigmatism, the distortion due to it 
in the inverted image will be the opposite to that produced in the erect image — 
i. e., in the example given the papilla in the inverted image would appear trans- 
patient's far point is between him and the observer; and in all other eases — in 
less degrees of myopia, in emmetropia, and in hypermetropia — moves "with" the 
mirror. — D.] 

* [This is not so much an evidence of the image's being inverted as of its being 
in front of the eye. The image of the fundus, in fact, appears to move to the right 
when the observer moves his head to the left, because it lies in front of the plane 
of the pupil to which its movements are referred. On the other hand, in hyper- 
metropia the image of the fundus appears to move in the same way that the ob- 
server does, because the image then lies behind the plane of the pupil. The con- 
ditions are the same as when we are on a moving train and, looking out at the 
telegraph poles near the track, backed by trees in the distance, the trees appear to 
move in the same direction as the train, and the telegraph poles in the opposite 
direction, the movements of both being projected upon some plane intermediate 
between the two. — D.] 



OBJECTIVE EXAMINATION OP THE EYES. 25 

versely oval. (This, however, is only the case when the convex lens used for 
forming the inverted image is held close to the patient's eye. If the lens is 
gradually carried ofi, the papilla appears first round, and finally a transverse 
oval.)* 

Detbkmination of DirFERBNCEs OF Lbvel in the Fundus.— Differences 
of level can not only be appreciated, but also precisely measured by means of 
the ophthalmoscope. This is effected with the aid of the erect image, by 
means of which the refraction can be determined for every point separately of 
the visible fundus. If a point in the fundus projects above its surroundings^ 




Fig. 17.— Parallactic Displacement of the Inverted Image of Points op the Fundus, 
LYING AT Different Levels. 

as, for instance, the swollen papilla in neuritis, the axis of the eye correspond- 
ing to this point is shorter — that is, there is a hypermetropia. By determining 
the degree of the hypermetropia we can compute the height of the prominence. 
Conversely, a point of the fundus which lies farther back (for example, the 
bottom of an excavation) possesses myopic refraction, from which the linear 
measure of the amount of depression can be found. As the basis of this com- 
putation the rule holds that a difference of level of about one millimetre cor- 
responds to a difference of refraction of 3 D. 

Differences of level of the fundus are also made apparent in the inverted 
image \>y parallactic, displacement. We proceed for this purpose by moving the 
convex lens which serves for the production of the inverted image a little up 
and down during the examination. If the points of the fundus which we have 

* [The fact that the papilla appears to change its nhape as the convex lens is 
withdrawn from the patient's eye is of itself a proof of astigmatism. On the other 
hand, an apparent change in size of the papilla, without change of shape occurring 
when the convex lens is gradually withdrawn, points to simple hypermetropia or 
myopia — to the former if the disk appears to diminish, and to the latter if the disk 
appears to enlarge. If the convex lens is placed so that its focal point is a little 
farther from the eye than the anterior focus of the latter (i. e., is rather more than 
half an inch in front of the cornea), there will be no distortion of the image of the 
disk from astigmatism, and no apparent increase or diminution in size due to 
myopia or hypermetropia. As this is the position of the lens which gives an 
undistorted view of the fundus, it is the one that should habitually be used in 
making examinations by the indirect method — i. e.. a 2-inch lens should be held 3J 
inches, and a 3-inch lens 8-J- inches in front of the cornea. — D.] 



26 EXAMINATION OP THE EYE. 

fixed upon lie all in the same plane, they do not change their relative position 
to each other -with the shifting of the convex lens. If, on the contrary, a dif- 
ference of level exists between them, we notice a displacement with relation to 
each other, so that they now come nearer together, now go farther apart. Fig. 
17 may elucidate what takes place. Let a be a point on the edge, 6 a point 
behind it, on the bottom of an excavation of the optic nerve. If the convex 
lens stands at I, the images of the two points ai and i, fall behind each other 
and cover each other. If the convex lens is now brought to II, the image of 
the point a is reproduced at a^, that of J at Jj ; the points appear to have sepa- 
rated from each other. Had the convex lens been carried in the opposite di- 
rection, the apparent displacement of the two points would have taken place 
in the opposite sense ; it would have looked as if the edge of the excavation 
had been drawn over the bottom of it. From the magnitude of the displace- 
ment the difference of level of the two points can be estimated, but can not be 
exactly computed, as is possible with the aid of the erect image. 



CHAPTER II. 

FUNCTIONAL TESTING. 

I 

4. Besides instituting the objective examination, we have further 
to test the function of the eye. In doing this we are limited almost 
entirely to the statements of the patient, so that in this respect we are 
quite dependent upon the latter's intelligence and good will. 

Our visual sensations are of three different kinds, inasmuch as in 
looking at objects we take cognizance of their form, their color, and 
their brightness. The faculty by which we recognize the form of ob- 
jects is called the space sense, and finds its numerical expression in the 
visual acuity ; the faculty by which we distinguish colors constitutes 
the color sense; the faculty by which we distinguish different degrees 
of brightness constitutes the light sense. These three faculties are 
resident in the retina throughout its entire extent, although in very 
different degrees. In this regard we must distinguish between central 
and peripheral vision. 

Central or direct vision is vision with the fovea centralis. When 
we wish to see an object distinctly, we " fix " it — that is, we turn the 
eye in such a way as to make the image of the object fall upon the 
fovea centralis, as the latter, on account of its peculiar anatomical 
structure, gives us the sharpest vision that we are capable of. It is 
with reference to central vision that we test the refraction, the accom- 
modation, and the visual acuity. For more precise particulars in re- 
gard to these tests, see the third part of this book, which treats of the 
optical defects of the eye. 

Peripheral or indirect vision is vision with those parts of the retina 
which do not belong to the fovea centralis and which comprise by far 
the greatest part of the retina. Vision with the peripheral portion of 
the retina affords a less distinct, a duller sensation, of which we can 
best get an idea by holding the outspread fingers of our hand to one side 
of the eye, while the latter is looking straight ahead. The farther from 
the fovea centralis is the image produced upon the retina, the more in- 
distinct is the perception of its shape. For perceptions of movement, 
on the other hand (Bxn^r), as well as of slight differences of luminosity, 
the periphery of the retina is actually more sensitive than the center. 

27 



28 EXAMINATION^ OF THE EYE. 

Of what use, then, is peripheral vision, if we can get no well-defined 
perceptions with it ? We can best understand this by observing per- 
sons who have lost peripheral vision to such an extent that only the 
fovea centralis and its immediate vicinity retain their functional 
activity, as happens in many diseases, especially in retinitis pigmentosa. 
Such persons can sometimes still read the finest print, and yet are in 
no condition to go about alone. We can put ourselves in this condi- 
tion if we fasten in front of the eyes a long tube which allows us to see 
only the point lying directly in front of our line of vision. We can 
not go about with such an apparatus, because we strike against objects 
everywhere. Peripheral vision, therefore, is of service in orientation. 
How ? If, as we are walking, we look straight before us and there is a 
stone lying in our path, the latter forms an image in the periphery of 
the retina of our eye, in this case in the upper part of it. The stone, 
to be sure, is not distinctly perceived, but still it excites our attention. 
Our gaze is then directed at it ; it is seen directly ; we recognize it as 
an obstacle, and avoid it. The same thing happens if we go out upon 
the street and men come toward us from one side, etc. The images 
falling upon the periphery of the retina give us warning signals which 
make us cast our eye directly upon the objects which excite the 
images. And it is precisely moving objects that are most sure to 
attract our attention, since, as just stated, the peripheral portions of 
the retina have a high degree of sensibility for the perception of 
movement. 

5. Examination of the Field of Vision.— The examination of the 
field of vision — that is, of the limits of indirect vision — must be made 
for each eye separately. The eye examined is directed at a fixed 
point, in order that it may thus remain steadily in the same position, 
while the other eye is kept closed. 

The simplest way of investigating the extent of the field of vision 
is by using the hand as a test object. The physician places himself 
directly in front of the patient and at a short distance from him ; the 
patient looks with one eye at the physician's eye directly opposite. 
The physician now closes his other eye (as does the patient), and 
gradually moves his hand from the periphery inward over the limits of 
the field of view ; the patient must tell as soon as he sees the hand. 
In this way the physician has in his own eye a means of judging the 
field of view of the patient ; if this is normal, the patient must see the 
hand at the same time that the physician does with his eye. This 
method is sufficiently exact for the recognition of the larger encroach- 
ments upon the visual field ; but small defects can not be thus recog- 
nized. It is the only method of testing applicable in those cases in 
which smaller test objects are no longer made out because the vision is 
too poor. If the patient is lao longer in condition to see even the 
hand, we must make use of a candle flame which we carry about 



FUNCTIONAL TESTING. 



29 



through the field of vision. In this way, for instance, we test the vis- 
ual field of a person who is blind from cataract. 

We can get at the field of vision more exactly by means of a Mach- 
hoard. We place the patient 
before this and take care that 
during the examination the dis- 
tance between the eye and the 
board remains always the same 
(e. g., 30 cm.). Directly oppo- 
site the patient's eye we make 
a mark on the blackboard with 
chalk, and direct him to fix his 
gaze on this mark during the 
examination. The chalk is now 
gradually brought from the edge 
of the blackboard to its center, 
and the patient is to tell at what 
moment he first sees it. By 
marking on the blackboard the 
limits of the visual field in every 
direction and connecting the 
points thus determined, we fix 
the extent of the field of vision. 
The size of the latter is, of 
course, in direct proportion to 
the distance at which it is taken. 

Even this method is not en- 
tirely free from drawbacks which 
spring from the difficulty of 
projecting a hollow sphere like 
the retina upon a plane. One 
important drawback is that un- 
equal distances in the field of 
vision correspond to equal dis- 
tances on the retina. Thus, in 
Fig. 18, the distances m a and 
i c upon the retina are equal, 
each corresponding to an angle 
of ten degrees. In the field of 
vision projected on the board, 
T T, however, the section (from 
70° to 80°) that corresponds to 

the second region of the retina is many times greater than that (from 
0° to 10°) which corresponds to the first. Hence, a spot upon the 
retina of definite size that has become insensitive to light would in such 




Hog 

o.2o 






m ■ 

c ^ -* «^ 



* ^ ss 

^ £ 2 o 

1-1(4-1 '3 O 

(u eg « y 
^ Dj o g 






o p, 



5.2 ■a 



S "iS t. 

> \jg OJ 

t^ ed ^ 0) 

_ O 03 ft 

2 ftfl gJ 

cc tea) g 



30 



EXAMINATION OF THE EYE. 



a visual field appear as a gap, the size of which would be quite different 
according as it is nearer to or farther from the center, and thus mis- 
takes might be caused. A second evil is that the whole of a normal 
visual field does not find a place on a plane, be the latter ever so large. 
The normal field of vision, that is, extends outward to 90° and more. 

Right Eye. 
360 







Fio. 19. 



ISO 

-Field of Vision op the Right Eve for White, Blue, Red, and Qreen, for a Test 
Object of 20 Square Mm. (After Baas.) 

F^ point of fixation ; M, Mariotte's blind spot. 



Therefore, as is evident from Fig. 18, the temporal limit of the visual 
field can never be projected on the board. 

After what has been said, therefore, there is only one exact method 
of representing the visual field, and that is the projection of it upon a 
hollow sphere (Aubert). Upon this principle different perimeters are 
constructed. To Forster belongs the credit of having introduced this 
instrument into ophthalmic practice. Forster's perimeter consists, not 
of a complete hemisphere, but of a metallic semicircle (Fig. 18, P) 
which represents, as it were, one meridian of the hemisphere. The 
semicircle is capable of being revolved so as to take the direction of 
each meridian in succession. The patient supports his head on a chin 



PUNCTIOKAL TESTING. 



31 



rest which is so placed in front of the semicircle that the eye to be ex- 
amined is situated in the center of curvature of the latter. In the ex- 
amination the eye must be fixed upon the middle point of the semicir- 
cular arc, while the mark that serves for the test is carried to and fro 
along the latter. A scale of degrees marked upon the semicircular arc 
enables us to read ofE directly the situation of the boundary of the vis- 
ual field, and the result obtained is transferred to a diagram (Fig. 19). 

6. Extent of the Field of Vision.— The normal field of vision, as a 
glance at the appended diagram (Pig. 19) shows, does not by any 
means extend equally far in all directions. It stretches farthest 
toward the external (temporal) side, where it has an extent of over 
90°. Accordingly, we can still see objects on the temporal side, al- 
though they lie in, or even somewhat behind, a plane passing through 
the pupil (for example, the point in Pig. 18). This is rendered pos- 
sible by the fact that the rays from such a point undergo such strong 
refraction at the surface of the cornea that they can still enter the 
pupil. The field of vision is much less extensive in other directions, 
especially in directions inward and upward. The cause of this is to be 
sought for in the fact that the nose and the eyebrows project into the 
field of view and limit it. This obstacle can indeed be partially over- 
come by making suitable rotation of the head while the field of vision 
is being examined, but even then we never find the field of vision as 
extensive on the nasal side as it is on the temporal. The cause of this 
is that the margin of the percipient layers of the retina does not 
extend as far forward on the temporal side as on the nasal (Pig. 18, d 
and e). 

The pathological alterations of the visual field consist in its cur- 
tailment. This is either produced by a pushing in of the boundary of 
the visual field at some point, or it occurs under the form of gaps lying 
like islands inside of the field of vision. 

Narrowing of the visual field at the periphery presents varying 
characters. If the limits of the visual field are brought nearer to the 
center from all points alike we speak of a concentric contraction. 
When this is considerable, it results in that incapacity for orientation 
which has been already described, although it may be that direct vision 
(visual acuity in the narrower sense) is still quite good. In other cases, 
the contraction extends from one side only of the periphery into the 
visual field. If it has the shape of a triangle whose base corresponds 
to the periphery of the visual field, it is called a sector-shaped contrac- 
tion. A peculiar variety of contraction of the visual field is the hemi- 
opic, in which exactly one half of the field is wanting (see § 100 and 
Figs. 153 and 153). 

Islandlike gaps in the visual field are called scotomata* One of 

* From itk6tos, darkness. 



32 EXAMINATION OP THE BYE. 

these exists in the healthy eye at that point of the visual field which 
corresponds to the entrance of the optic nerve, and is known as Mari- 
otte's blind spot (Fig. 19, M). In the field of vision it lies about 15° 
to the outside of the point of fixation, F. The scotomata which occur 
as the result of disease have a very different significance for vision ac- 
cording to their situation ; and, according to the latter, we distinguish 
them into central and peripheral. A central scotoma is one which in- 
volves the point of fixation (cf. Pig. 158). In this case direct vision is 
either greatly diminished or is abrogated altogether. The patient can 
no longer do any fine work, although his power of orientation remains 
intact. Peripheral scotomata cause little disturbance of sight, espe- 
cially if they lie far from the point of fixation, in which case they may 
not come to the patient's knowledge until his visual field is being 
examined. A special variety of scotoma is the annular, which encircles 
the point of fixation like a ring (which is not always completely closed), 
but leaves intact the point of fixation itself. 

Von Graefe was the first to call attention to the importance of testing the 
visual field in ophthalmic practice. He showed that for many intra-ocular dis- 
eases there are special varieties of contraction of the visual field, which are more 
or less characteristic of these diseases, and can be utilized for their diagnosis. 
Since then the study of the visual field has been much cultivated, so that at 
present its examination has great significance, both for diagnosis and prognosis. 

ConcenPric contraction of the visual field, associated with retention of good 
central vision, we meet with especially in retinitis pigmentosa, and sometimes 
also in glaucoma. In other diseases which are frequently accompanied by con- 
centric contraction of the visual field, as, for instance, in atrophy of the optic 
nerve or of the retina, central vision is also simultaneously and markedly 
affected. 

We find the sector-shaped deficiencies especially in atrophy of the optic nerve ; 
also in occlusion of one of the larger retinal arteries, when the sector-shaped 
district of the retina supplied by such an artery has its function abrogated. We 
observe more extensive, although not triangular, contractions of the visual field 
in detachment of the retina, and these most often extending in an upward di- 
rection, since the detachment, if of long standing, generally involves the lower- 
most part of the eye. In glaucoma a contraction of the visual field toward the 
nasal side is of relatively frequent occurrence. 

Scotomata are most frequently met with in diseases of the fundus with cir- 
cumscribed lesions ; especially, therefore, in chorioiditis disseminata, in which, 
as a rule, the gaps in the visual field correspond to the separate macuto visible 
with the ophthalmoscope. So long as these gaps afifect the periphery only of 
the visual field, they cause little disturbance of sight. If they are very numer- 
ous, the visual field acquires a sievelike character. If, finally, one of the cho- 
rioiditic masses is localized at the region of the chorioid corresponding to the 
yellow spot, the visual power is very considerably reduced by the formation of a 
central scotoma in addition to those in the periphery. 

Isolated central scotomata occur in diseases of the retina and chorioid at the 
posterior pole of the eye, especially as a result of syphilis, of myopia of a high 
degree, and of senile changes. In all these cases there corresponds to the sco- 



FUNCTIONAL TESTING. 33 

toma a change in the macula lutea, visible with the ophthalmoscope. In 
another series of cases, on the contrary, a central scotoma exists, -while the 
result of the ophthalmoscopic examination is negative ; the cause of the scotoma 
is then to be looked for in the optic nerve. In the latter it is just those fibers 
■which supply the region of the macula lutea that are the most favorite seat of 
disease (in retrobulbar neuritis; see § 103). 

As the expression scotoma is used in different senses, it will require in this 
place a more precise explanation. We distinguish between positive and nega- 
tive scotomata (Forster). 

By a positive scotoma we understand a dark spot which the patient perceives 
in his visual field — projects, that is, upon some portion of his visual field. The 
cause of a positive scotoma lies either in the refracting media or in the retina. 
Opacities in the refracting media throw their shadow upon the retina, and are 
therefore visible as dark spots. If the opacities lie in the vitreous they are 
motile (muscaa volitantes), and the scotomata caused by them axe characterized 
as motile scotomata. Fixed scotomata originate either from stationary opaci- 
ties (e. g., those in the lens), or, still more frequently, from changes in the 
fundus (e. g., from an exudation in the retina or in the chorioid adjacent to it). 
Scotomata of the latter kind are best brought to light by making the patient 
fix his gaze upon a uniformly bright surface (e. g., a sheet of white paper). 
They are often more readily perceived if the illumination is at the same time 
diminished (as by letting down the window curtains). We can direct the 
patient to make a copy of the dark spots that become visible upon the paper, 
and from this we can determine the position and extent of the diseased portions 
of the retina. 

We characterize as a negative scotoma a hiatus in the visual field, an isolated 
spot within the confines of which the patient does not perceive any external 
objects. Such a scotoma, accordingly, is not discovered as a rule until the 
visual field is examined. But there is nothing to prevent a negative scotoma 
from being at the same time a positive one too; the same diseased regions of 
the retina that are insensitive to external luminous impressions can at the same 
time be themselves perceived as dark spots and be projected exteriorly. 

Negative scotomata are divided into absolute and relative. An absolute 
scotoma is present if within its limits all perception of light is wanting, while 
with relative scotomata the perception of light is merely diminished. We dis- 
cover a relative scotoma by making the examination of the visual field with 
small objects, and especially by choosing colored objects for this purpose. 
For with a certain diminution of the visual power the ability to distinguish 
colors accurately disappears, while the objects themselves, owing to differences 
in their luminosity, can still be recognized. For example, in a recent case of 
chronic poisoning by nicotine, the visual field, measured with the aid of a 
white test object, may seem quite normal ; but if a small red paper disk is 
chosen for the examination there is a small region in the center in which the 
disk is no longer recognized as red. A relative scotoma is present, and that, 
moreover, a color scotoma (scotoma for red). 

Even in the normal visual field the perception of colors is not everywhere 
the same. Just as in regard to the visual acuity, so also in regard to the color 
sense, a distinction must be made between central and peripheral color percep- 
tion. While the former is tested by the mere exhibition of colored samples, 
the latter must be investigated, just like the visual field, by using as test objects 



Si EXAMINATION OP THE EYE. 

colored marks, which are moved to and fro on the board or on the perimeter. 
The bigger and brighter the colored surfaces used for this purpose are, the fur- 
ther toward the periphery will their color be distinguished, and when very 
large and bright they will be distinguished up to the extreme limits of the 
field. But when the examination is made with the ordinary test objects used 
with the perimeter (colored squares of paper, 1 to 3 cm. in diameter), the 
most peripheral portions of the retina are found to be color blind. If such .? 
colored square is pushed from the periphery of the visual field toward the cen- 
ter, the person examined at first recognizes only the presence of a moving 
object. It is not till the square approaches nearer the center of the visual field 
that its color is correctly given. The moment when this occurs is not the same 
for all colors, some being recognized farther out from the center than others. 
The visual field for green is the smallest, that for red somewhat larger, that for 
yellow still larger, that for blue the largest (see Fig. 19). 

The examination of the visual field with colored objects is of great practical 
importance. For instance, we find in one case the visual field normal when 
tested with white, while the examination with colors shows already a consider- 
able introcession of its borders at one spot. After some time, if the disease has 
progressed, we now, on testing with white, establish the same deficiency in the 
visual field that had before existed for colored objects only. The examination 
with colors is accordingly a more delicate test than that with white ; it makes us 
discover a diminution of the visual power before it has advanced so far that a 
white object can no longer be recognized. If, therefore, we take two cases in 
which the visual field for white is equally large, but the visual field for colors 
is unequal, that case in which the visual field for colors is smaller affords the 
worse prognosis, since here a still further diminution of the general visual field 
is to be expected. Rapid diminution of color perception is pre-eminently 
associated with the progressive lesions of the optic nerve that lead to blind- 
ness. The examination of the visual field with colors is also requisite for the 
recognition of central scotomata, so long as they are not absolute. 

Furthermore, the way in which the color sense is diminished gives us a 
clew as to the site of the morbid changes. Thus diminution in the perception of 
blue corresponds to a lesion of the percipient elements (rods and cones) of the 
retina, such as occurs in chorioiditis, retinitis, and hemeralopia ; diminution in 
the perception of red and green to a lesion of the conducting elements, as in 
affections of the optic nerve. 

Light Sense.— Let us assume that we have before us two persons who in 
ordinary daylight have the same visual acuity ; both under equally good 
illumination read print of the same size at the same distance. We now gradu- 
ally lessen the illumination. As a result of this, the difference in brightness 
between the black letters and the white paper diminishes and the letters are dis- 
tinguished with greater and greater difficulty. At a certain stage in the process 
of obscuration, one of the two persons ceases to recognize the print while the 
other is still able to read, and the darkening has to be carried further in order 
to make reading impossible for him. In this case we say : The two persons 
have the same space sense, i. e., the same susceptibility of the retina for impres- 
sions of forms, but they have a different light sense (i)— i. e., a different sus- 
ceptibility for impressions of brightness and of differences of brightness. 

The light sense can be tested in various ways. We determine either the 
lowest Umit of illumination with which an object is still visible (minimum 



E^UNCTIONAL TESTINa. 



35 




Fig. 20.— Photometer of FOrster. 



stimulus) or the smallest difierence in brightness which can still be appreciated 
(minimum of differentiation). The most usual method of measuring the light 
sense is with Forster's photometer, which gives the minimum stimulus. This 
instrument, which is represented in horizontal section in Fig. 20, is placed in a 
perfectly dark room. A box. A, blackened on the inside, bears on its anterior 
wall two apertures for the two eyes, a and a,, which look through these aper- 
tures at a plate, T, which is placed upon the posterior wall, and upon which 
large black stripes upon a white ground are placed as test objects. The illu- 
mination is produced by a normal candle,* £, the light from which falls through 
a window, F, into the inte- 
rior of the box. In order 
to make the illumination 
perfectly uniform, the win- 
dow is covered with paper 
which is made translucent 
(by impregnating it with 
fat). By a screw, 8, the size 
of the window can be al- 
tered from complete closure 
up to an aperture of five 
square centimetres. In this 
way the illumination of the 
plate is varied. The patient 
is then made to look into the apparatus with the window closed and the plate 
therefore unillumined. Then the window is slowly opened until the stripes 
upon the plate can be recognized. The size of the opening requisite for this 
purpose gives a measure of the light sense of the person examined. In con- 
ducting this examination the precaution must be adopted of making the person 
that is examined stay beforehand in darkness. If we come from daylight into 
a moderately darkened room we see so little for the first moment that we can 
not move about without stumbling over the objects in the room. The longer 
we remain in the latter the better we see, and at last perhaps see well enough 
to be able to read. This we call adaptation of the retina. In the examination 
of the light sense, a period of adaptation of ten minutes, which the patient 
must pass with bandaged eyes in a perfectly dark room, is sufiicient for prac- 
tical purposes. 

The examination of the light sense in different diseases has shown that it is 
not always by any means diminished in proportion to the visual acuity, but is 
sometimes but little diminished, sometimes excessively so, a circumstance from 
which diagnostic points may be gathered. The diminution of the light sense 
is greatest in those cases which are characterized as hemeralopia (see § 104). 

SiMDLATiOK or BLINDNESS. — In testing the function we shall at times have 
to reckon with the fact that the patient is purposely trying to lead the physician 
astray by simulating blindness or weakness of sight when these do not exist. 
This most frequently occurs with those persons who wish to be relieved of mil- 
itary service or who wish to get testimony as to their inability to work ; some- 
times also with children, hysterical persons, etc. We are first led to suspect 
simulation by the lack of agreement between the results of the functional test- 



[* I. e., one of one-candle power, — D.] 



36 EXAMIXATION OP THE EYE. 

ing and of the objective examination; an eye, for example, which is alleged to 
be perfectly blind presenting no pathological changes of any sort. Or the 
tests of the individual functions give contradictory results, inasmuch as the 
visual acuity, the field of vision, the color sense, etc., do not stand in the right 
relation with each other and with the result of the objective examination. 
Various methods of examination have been proposed for furnishing a certain 
proof of simulation ; we shall accomplish this more or less readily by their aid 
according ;to the degree of skill of the simulant. Only some of these methods 
need be here adduced. 

Complete blindness of both eyes is. rarely simulated; much oftener it is 
simply unilateral blindness that is alleged ; and still more frequently a feeble- 
ness of sight actually present in one eye is exaggerated (aggravation). In the 
case of an alleged complete blindness of one or both eyes we regard in the first 
place the reaction of the pupil to the light. If this is well preserved, it will 
always afford a strong ground for suspecting simulation, although there are 
rare cases in which in the presence of actual blindness the pupillary reflex for 
light is still retained (see § 64;. Sohmidt-Kimpler recommends the following 
procedure : The patient is made to look with the blind eye at his own hand, 
which he holds in front of him. A blind man will do this without hesitation 
since he is informed of the position of his hand by the sense of feeling; a 
malingerer will perhaps look purposely in the wrong direction. Simulated uni- 
lateral blindness can also be discovered in the following way : A lighted candle 
is brought in front of the good eye and is slowly carried toward the side of the 
blind eye. The patient is detected if he declares that he still sees the candle at 
the moment when it is just concealed from the sound eye by the dorsum of the 
nose (Cuignet). 

The following methods are furthermore of service in detecting the simula- 
tion of unilateral blindness or amblyopia. 

1. We make the patient read, and then hold a pencil in a vertical direction 
between the eye and the book. If there is vision with only one eye the pencil 
conceals certain words from it, and thus interferes with reading. If, however, 
there is good vision with both eyes, those letters which are concealed from one 
eye by the pencil are visible to the other, and vice verm, and reading is carried 
on without difficulty (Cuignet). 

3. A convex glass of 6 D. is placed before the sound eye. In this way the 
eye is made artificially myopic, so that its far point lies at a distance of about 
17 cm. (it being presupposed that the eye is emmetropic). The eye can there- 
fore read fine print only at a distance of 17 cm. or less, but no farther. After 
placing the glass before the eye we first make the patient read at quite a short 
distance, and then slowly and imperceptibly move the book farther and farther 
away. If it is possible in this way to withdraw the book considerably farther 
than 17 cm. without the patient's ceasing to read, it proves that he has been 
reading with the eye alleged to be bad. That is, he began reading with the 
good eye and, when the book was carried too far oS for that, continued witli 
the other eye, without noticing the alternation in the employment of the two 
eyes. 

3. We make a show of occupying ourselves with the sound eye only. We 
take a strong prism (one of 18°), with the base up, and, first holding it in 
front of the cheek, push it gradually up in front of the eye. Before the base 
has reached the center of the pupil the eye will see double. For two images 



FUNCTIONAL TESTING. 



3Y 



of every external object will be thrown upon the retina, one transmitted 
through the free half of the pupil, the other through the half covered by the 
prism, and the eye sees double the object upon which it is fixed (monocular 
diplopia)— a fact which the patient will admit without hesitation, since, of 
course, it is the sound eye only that is concerned in the matter. Now the 
prism is imperceptibly pushed along until it covers the entire pupil. Now the 
eye that is provided with the prism again has only one single retinal image, 
which, however, is thrown upon a higher point of the retina than is the case 
in the other eye. If now there is still double vision (binocular diplopia), it is a 
proof that both eyes see. If -^ve use the test types for this examination and com- 
pel the person under examination to read sometimes the upper, sometimes the 
lower of the two double images, we can determine directly the visual acuity of 
each eye separately without the patient being aware of it (Alfred Graefe). 

4. Snellen has constructed a board with test types which are alternately red 
and green. Before the patient is allowed to read it, a pair of spectacles is put 
upon him, in wliich are introduced a red glass for one eye and a green glass for 
the other. Through the red glass the red letters alone, and not the green, can 
be seen, because green is the complementary color of red, and therefore green 
rays are not transmitted through red glass. For the same reason the red letters 
can not be perceived through the green glass.* If, therefore, any one who is 
blind in one eye looks through these spectacles at the test types, he will read 
off only the red, or only the green letters, according as the red or the green 
glass of the spectacles is placed in front of the eye which alone can see. He 
will not once suspect that still other letters of a different color lie between the 
letters that he has read. Should the patient, on the other hand, read all the 
letters, it proves that he sees with both eyes and in such a way as to recognize 
the red letters with one eye and the green with the other. 

5. Letters are written on white paper with a black and a red pencil alter- 
nately. The subject under examination is then told to read the writing rap- 
idly, while a red glass is held before the sound eye. If he reads the whole 
correctly, it is a proof that he is able to read with the eye alleged to be blind, 
for the sound eye, looking through the red glass, can not see the red letters, 
since these now offer no contrast to the background upon which they are 
viewed, which appears as red as they. 

For the tests for the motility of the eye and for binocular vision, see § 132. 

* [In this test of Snellen's the red and green letters are transparent and placed 
upon an opaque ground and are hung up before a window so as to be seen by 
transmitted light. In this case, as stated in the text, only the red letters are seen 
through the red glass, and only the green through the green glass. The same will 
occur if the red and green letters are opaque, and placed on a dull black ground, 
and viewed by reflected light. In either case the conditions are opposite to those 
which exist in the test next mentioned, in which opaque red letters are viewed by 
reflected light on a white ground. — D.] 



PAET II. 
DISEASES OF THE ETE 



CHAPTEE I. 

DISEASES OF THE CONJUNCTIVA. 

Anatomy. 

7. The conjunctiva coats the posterior surface of the lids and the 
anterior surface of the eyeball. It forms a sac, the conjunctival sac, 
which is slit open anteriorly in a line corresponding with the palpebral 
fissure. In the conjunctiva we distinguish three divisions. That part 
of the conjunctiva which covers the posterior surface of the lids and 
which is closely adherent to the tarsus is called the conjunctiva tarsi ; 
that division which coats the anterior surface of the eyeball is the con- 
junctiva bulbi. The connection between the two is formed by the 
third division, which we name the transitional part of the conjunctiva 
(conjunctiva fornicis). That region where the conjunctiva is reflected 
from the lids to the eyeball and which forms the bottom of the con- 
junctival sac is called the fornix conjunctivae. 

We get a view of the conjunctiva tarsi in the living eye by evert- 
ing the lids. It has a smooth surface and is intimately and immova- 
bly adherent to the subjacent tarsus (Fig. 21, t). (It is therefore im- 
possible to cover up losses of substance of the palpebral conjunctiva 
by performing an operation to draw the adjacent conjunctiva over 
them, as is often done with the conjunctiva bulbi.) On account of its 
thinness, the conjunctiva tarsi allows the Meibomian glands, which lie 
in the tarsus itself, to be seen through it clearly. 

The microscope shows that the palpebral conjunctiva is covered 
with a laminated cylindrical epithelium. The mucous membrane 
proper is of adenoid character — that is, even in the healthy state it 
contains an abundant quantity of round cells (lymph corpuscles), which 
notably increase in number with every inflammation of the conjunctiva. 
Of glands it possesses acinous mucous glands, which are found along 
the convex border of the tarsus (Pig. 31, m>; Waldeyer) ; analogous 
glands (Kranse's glands, Fig. 162) are present in the fornix conjunctivse. 
38 



DISEASES OF THE CONJimCTIVA. 



39 



The conjunctiva of the upper lid obtains its blood supply from two 
arterial arches, the arcus tarseus superior {as, Pig. 21) and the arcus 
tarseus inferior (at, Fig. 31). These lie upon the anterior surface of the 




Fig, 21.— Perpendicular Section through the Upper Lid. Magnified 5x1. 

The skin of tlie lid ]oresents in the upper part, above a sulcus, the protecting fold, d ; below, it 
covers the anterior edge of the lid, v. In the skin are found fine hairs, e, e, sweat glands, a, 
cilia, c, c, c, and in the neighborhood of the latter Zeiss's glands, z, and the modified sweat 
glands, s. Beneath the skin lie the transversely divided bundles of fibers of the orbicularis, 
o, o, of which those placed most internally, r, r, form the musculus ciliaris Riolani. The 
posterior surface of the lid is covered by conjunctiva which is intimately adherent to the 
tarsus, f, and over the latter shows isolated papillae, especially at co, over the convex border 
of the tarsus. Still higher up, at h, in the vicinity of the fornix, the conjunctiva shows an 
adenoid character. The Meibomian glands, g, have their orifices, vi, in front of the poste- 
rior edge, ft, of the lid ; above them he Waldeyer's mucous glands, w, and still higher Miil- 
ler's musculus palpebralis superior, p, and the levator palpebrse superioris, I. From the 
latter the leash of fibers, I, passes to tne skin of the lid. as is the arcus tarseus superior ; at, 
the arcus tarseus inferior ; from the latter the rami perforantes, rp, run, at first straight 
downward, then backward, through the tarsus. 



tarsus, near its upper and its lower edges. To reach the conjunctiva, 
the branches of the arcus tarseus inferior (rp, Fig. 21) perforate the 
tarsus through its entire thickness from before backward, two to three 



40 DISEASES OP THE EYE. 

mm. above the free edge of the lid. The line along which the vessels 
come out from the tarsus is marked by a shallow furrow (sulcus sub- 
tarsalis) on the conjunctival surface of the lid. On the lower lid there 
is only one arterial arch. 

The conjunctiva of the region of transition is very readily brought 
to view in the lower lid by drawing the lid down while the eye looks 
up. In the upper lid, on the contrary, the fold of transition is hard 
to see, unless we make a double eversion of the lid. The region of 
transition is the loosest part of the conjunctiva, this being here so 
abundant that it lies in horizontal folds. This arrangement insures 
the eye its free power of movement. If the conjunctiva were to pass 
directly from the lid to the eye, as is sometimes observed in conse- 
quence of disease of the conjunctiva, every movement of the eyeball 
would be transmitted to the lids ; and if one of the lids was held still 
with the finger, the eyeball would be hampered by it in its movements. 
But the conjunctiva is present in such quantity at the fornix that the 
eye is able to move in complete independence of the lids, the folds in 
the region of transition being smoothed out or crumpled together, as 
the case may be. Appearing through the lower fold of transition are 
the extensive subjacent plexus of veins and also the white glistening 
fascia. Its lax character and also its abundant blood supply render the 
fold of transition particularly liable to great swelling in inflammations 
of the conjunctiva. 

The conjunctiva bulbi covers the anterior surface of the eyeball. It 
has no aperture corresponding to the cornea, but continues, even if 
with altered character, over the latter. This continuity of the conjunc- 
tiva makes it plain to us why morbid processes of the latter do not stop 
at the margin of the cornea but are continued upon the surface of the 
latter, as we see very clearly in trachoma and in conjunctivitis ecze- 
matosa. The two divisions of the conjunctiva bulbi are distinguished 
as the conjunctiva scleras and conjunctiva corneas. The conjunctiva 
corneas is perfectly transparent, and is so intimately adherent to the 
cornea proper that it must be regarded as the uppermost layer of the 
latter, and is better treated of at the same time with the cornea itself 
(see § 27). 

The conjunctiva scleree covers the anterior segment of the sclera in 
the form of a thin pellicle. It is connected with the sclera by lax con- 
nective tissue (the episcleral tissue) so loosely that it can readily be 
moved about from side to side upon the sclera. It is only at the pe- 
riphery of the cornea, where it ends in a sharp edge, the limbus* con- 
junctivas, that the conjunctiva scleras is intimately adherent to its sub- 
stratum. It is very thin and elastic and lets the white sclera be seen 
through it plainly, thus forming the " white of the eye." In old people 

* Limbus, hem. 



DISEASES OE THE CONJUNCTIVA. 41 

there is a spot at tlie inner and the outer margins of the cornea which 
contrasts by its yellow color with this whiteness. This has the shape of 
a triangle with its base at the corneal margin, and projects a little 
above the rest of the conjunctiva. It is called the interpalpebral spot 
or the Pinguecula,* and is produced by the fact that that part of the 
conjunctiva which, being included in the interpalpebral fissure, is con- 
stantly exposed to atmospheric influences, has undergone an alteration 
in its tissues. 

The conjunctiva sclerse is covered with laminated pavement epithe- 
lium and contains no glands. At the inner angle of the eye it forms a 
crescentic duplication, the semilunar fold (plica semilunaris), which rep- 
resents an abortive remnant of the palpebra tertia of animals. To the 
inside of the semilunar fold is a small, reddish, nipplelike prominence, 
the caruncle,! which occupies the bottom of the horseshoe-shaped ex- 
cavation at the angle of the eye (Fig. 30, 0). This is shown to be his- 
tologically a small island made of skin, containing sebaceous and sweat 
glands and having its surface covered with delicate light-colored hairs. 

The conjunctiva of the eyeball receives its blood-vessels chiefly 
from the vessels of the fold of transition — the posterior conjunctival 
vessels (Fig. 32, o and Oi). Furthermore, the anterior ciliary vessels 
(Fig. 22, e and e-i) take part in supplying the conjunctiva with blood. 
These vessels come from the four recti muscles (R, Fig. 22) and run 
under the conjunctiva (through which they are visible, shining with a 
bluish luster) until near the edge of the cornea, where they suddenly 
.disappear, since they pass through the sclera into the interior of the 
eye. But, before this happens, they give off branches which end in 
vascular loops, in the limbus conjunctivae directly at the margin of the 
cornea (marginal network of the cornea— g, Fig. 22). This latter is 
of great importance for the cornea which is chiefly dependent upon it 
for its nutrition. Other branches of the ciliary vessels (anterior con- 
junctival vessels, p, Fig. 22) run backward in the conjunctiva toward 
the posterior conjunctival vessels and anastomose with them. 

We have therefore in the conjunctiva two vascular systems — that 
of the posterior conjunctival vessels and that of the anterior ciliary 
vessels. According as the one or the other system is overdistended 
with blood, the conjunctiva has a different aspect, which we designate 
respectively as conjunctival and as ciliary injection. 

Conjtmctival hijection presents to us a superficially disposed net- 
work of larger and smaller vessels, whose situation in the conjunctiva 
is proved by the fact that when it is moved about they move with it. 
The color of the injection is a vivid scarlet or brick-red ; the individual 
vascular meshes are plainly to be recognized. This injection is charac- 
teristic of diseases of the conjunctiva itself. 



* Pinguis, fat. t Caruncula, dim. of caro, flesh. 



42 



DISEASES OF THE EYE. 



Ciliary injedioji occurs as a rose-red or pale-violet zone round the 
cornea (hence the designation peri- [circum-] corneal injection), in 




Fig. 22.~Blood-vessels of the Eye (Schematic, after Leber). 

The retinal system of vessels is derived from the central artery, a. and the central vein, Oj, of 
the optic nerve, which give off the retinal arteries, 6, and the retinal veins, fc,. These end at 
the ora serrata. Or. 

The system of ciliarti vessels is fed by the posterior short ciliary arteries, c. c, the posterior long 
ciliary arteries, d. and the anterior ciliary arteries, e. From these arise the vascular net- 
work of the chorioidal capillaries, /, and of the ciliary body, g, and the circulus arteriosus 
Iridis major, h. From this last spring the arteries of the iris, i, which at the lesser [inner! 
circumference of the latter form the circulus arteriosus iridis minor, k. The veins of the 
iris, i|. of the ciliary body, and of the chorioid are collected into the vasa vorticosa, I; those 
veins, however, that come from the ciliary muscle (m) leave the eye as anterior ciliary 
veins, ^i- With the latter Schlemm's canal, n, forms anastomoses. 

The system of conjunctival vessels consists of the posterior conjunctival vessels, o and Oj. These 
communicate with those branches of the anterior ciliarj- vessels which run to meet them ; 
that is, with the anterior conjunctival vessels, p, and form with these the marginal loops of 
the cornea, g^ O. optic nerve ; S. its sheath ; »c, sclera ; A, chorioid ; N^ retina ; i, fens ; 
fl, cornea ; i?, internal rectus ; B, conjunctiva. 



DISEASES OE THE CONJUNCTIVA. 4.3 

which we are unable to recognize clearly any individual vessels. With 
injection of greater intensity we see, still farther removed from the 
cornea, a coarser network of vessels, which are to be recognized as 
deeply placed by their violet color and their hazy appearance ; by the 
fact, moreover, that when the conjunctiva is displaced they do not 
move with it. Ciliary injection is most markedly distinguished from 
that of the conjunctiva by its violet hue as well as by the diffuse ap- 
pearance of the redness, due to the fact that the individual engoro-ed 
vessels are recognized either indistinctly or not at all. Ciliary injection 
most frequently accompanies diseases of the cornea, and also of the iris 
and the ciliary body, parts which belong to the vascular district of the 
anterior ciliary vessels. On account of the numerous anastomoses be- 
tween the two vascular districts of the conjunctiva, we find both in- 
jected in every inflammation of any great violence in the anterior sec- 
tion of the eyeball ; it is, however, still generally possible to recognize, 
along with the superficial conjunctival injection, the ciliary injection, 
more deeply situated and directly surrounding the cornea. 

The conjunctiva of the tarsus is really perfectly smooth only in the young. 
In older persons we find it having a velvety surface on the upper lid toward the 
angles of the tarsus, and often also along the entire convex edge of the tarsus 
(Fig. 21, CO). This condition of the conjunctiva we call papillary. In reality, 
however, it is not, properly speaking, papillse which are here found in the 
conjunctiva, but fine folds into which the surface of the somewhat hypertro- 
phied conjunctiva has been thrown. In microscopic sections through regions 
of the conjunctiva, which have undergone this change, the transversely divided 
folds look like papillse, between which the epithelial lining dips down deeply. 
Should the sloping sides of two such folds lie very close to one another, the 
epithelial-lined depression between the folds can in cross-section give the im- 
pression of its being a glandular tube (i, Fig. 25). In this way is to be ex- 
plained the alleged new formation of tubular glands, which have been found in 
some cases of so-called papillary hypertrophy of the conjunctiva. Nevertheless, 
it is not to be denied that true tubular glands do exceptionally occur in the 
conjunctiva, both normal and diseased. These are called, after their dis- 
coverer, Henle's glands (Pig. 36, d). Furthermore, in middle and advanced 
life there are found, frequently in the fold of transition, less often in the palpe- 
bral conjunctiva, little yellow dots resembling the infarcts of the Meibomian 
glands (see § 108). This again is an instance of the new formation of tubular 
glands, in which develop concretions that are visible through the conjunctiva 
and then form the yellow dots. 

In the epithelium of the conjunctiva, particularly in its uppermost layers, are 
found cells which are undergoing a mucous metamorphosis {beaker cells). They 
occur but sparsely in the normal conjunctiva, but multiply to a great extent in 
inflammatory disorders of the latter. 

With regard to the papillary character of the conjunctiva at the upper 
border and at the angles of the tarsus, it is a question whether this is ever to be 
considered as perfectly normal and not rather as a product of repeated hyperss- 
mia of the conjunctiva. The same question must be put in regard to the ade- 
noid character of the conjunctiva, which is looked upon by many as also the 



44 DISEASES OF THE EYE. 

residuum left by a previous inflammatory irritation. Since this mucous mem- 
brane is exposed more than any other to external influences, attacks of hyperae- 
mia of it occur often to every man in the course of his life, and these may 
result in permanent alteration of the membrane. 

The action of external injuries shows itself most plainly in forming the 
Pinguecula. This corresponds precisely to that region of the conjunctiva which 
is most exposed to wind, dust, etc. This interpalpebral spot owes its name 
Pinguecula to its yellow color, which was formerly referred to deposition of fat 
in the conjunctiva. What actually exists, however, is a thickening of the con- 
junctiva, chiefly as the result of an increase in the number and size of its elastic 
fibers. Associated with this is the formation of numerous concretions of a 
yellowish hyaline substance, to which in fact the pinguecula owes its yellow 
color. As a result of these changes, the conjunctiva in this place becomes less 
transparent, for which reason the pinguecula appears most prominent when the 
conjunctiva bulbi is markedly reddened, whether from injection or from extrav- 
asation of blood. In this case the pinguecula does not allow the red color of 
the blood to shine through as plainly as does the adjacent conjunctiva that is 
not thickened, and the former, therefore, stands out from the red substratum in 
the form of a light-colored triangle, so that by beginners it is easily confounded 
with a diphtheritic infiltration of the conjunctiva, or, when the yellow color is 
pronounced, with a small pustule. 

I. COI^JUNCTIVITIS CaTARRHALIS. 

{a) Conjunctivitis Catarrhalis Acuta. 

8. Symptoms. — Acute conjunctival catarrh, in the liglder cases, 
chiefly affects the conjunctiva of the lids and of the region of transi- 
tion. The conjunctiva of the lids presents a vivid redness and is re- 
laxed. The injection is usually reticulate — i. e., the separate vessels 
can still be distinguished as such ; it is only when the injection is espe- 
cially dense that the conjunctiva acquires a uniformly red appearance. 
The surface of the conjunctiva is smooth ; catarrh is thus distinguished 
from some other forms of inflammation of the conjunctiva in which 
the latter is infiltrated and subsequently hypertrophied, as shown by 
the unevenness of its surface. The fold of transition (as well as the 
semilunar fold) is likewise greatly reddened and is somewhat swollen, 
while the conjunctiva bulbi shows little or no change. 

The severer are distinguished from the lighter cases by the fact 
that the process invades the conjunctiva bulbi. The redness and swell- 
ing of the palpebral conjunctiva are greater, and moderate oedema of 
the lids is often present at the same time. The conjunctiva of the 
eyeball shows both a dense reticulate reddening and a slight degree of 
swelling. Very frequently we find in the midst of the reticulate injec- 
tion red-colored spots— i. e., small haemorrhages, ecchymoses of the 
conjunctiva— produced by the rupture of small vessels. The severer 
cases, in which the conjunctiva is affected throughout its entire extent 
are designated under the name of ophthalmia catarrhalis, to distin- 



DISEASES OF THE CONJUNCTIVA. 45 

gnish tliem from the lighter forms, which are named simply conjunc- 
tivitis catarrhalis. 

Inflammation of the conjunctiva is accompanied by increased con- 
junctival secretion. This secretion appears under the form of flakes 
of mucus, swimming in the abundant lachrymal fluid. The more in- 
tense the inflammation the greater the secretion, and the more the 
character of the latter changes from mucous to purulent. Violent cases 
of ophthalmia catarrhalis, therefore, are in their inception often hard 
to distinguish from an acute blennorrhoea of light intensity, although, 
of course, the subsequent development of the case makes the diagnosis 
clear. The secretion which exudes from the palpebral fissure dries at 
night upon the edges of the lids and glues them together. 

The subjective symptoms consist of photophobia, and of itching and 
burning of the eyes. The intensity of the annoyance given depends 
naturally upon the degree of inflammation. Violent pains, however, 
are but rarely present, and then, as a rule, are excited, not by the catarrh 
itself, but by its complications (especially ulcers of the cornea). A very 
troublesome sensation that is frequently present is that of a foreign 
body being in the eye, caused by flakes and filaments of tough mucus 
in the conjunctival sac. If such filaments lie upon the cornea, they 
produce the disturbances of sight of which the patients sometimes 
complain. These are distinguished from visual disturbances of more 
serious character by the fact that clear vision is immediately restored 
by brushing the mucus off with the lids. It is a characteristic feature 
of catarrh that all its disagreeable characters are least pronounced in 
the morning, and afterward gradually increase until they reach their 
highest point in the evening. 

Course. — This is favorable in uncomplicated cases, the inflamma- 
tion disappearing spontaneously after from eight to fourteen days. 
Not infrequently, however, there remains a condition of chronic in- 
flammation (chronic conjunctival catarrh), which, to be sure, causes 
less annoyance than the acute stage, but which is yet protracted over 
a comparatively long time. In the majority of cases acute conjuncti- 
val catarrh attacks both eyes, either both simultaneously or one eye a 
few days after the other. 

The complications which are observed in catarrh are corneal ulcers 
and iritis. The development of corneal disease is manifested by an 
increase in the pain and photophobia. At first we recognize, in the 
neighborhood of the corneal margin, small gray points, which are ar- 
ranged in a row concentric with the corneal margin. On the days fol- 
lowing, these punctate infiltrations of the cornea become more numer- 
ous and at length confluent, so as to form a small gray crescent. By 
a process of superficial disintegration an excavation is produced, so 
that finally a crescentic ulcer is formed, situated very near the corneal 
margin and concentric with it. Such ulcers are characteristic of con- 



46 DISEASES OP THE BYE. 

junctival catarrh and are hence called catarrhal ulcers. Ordinarily 
the ulcer becomes clean quickly and heals, leaving behind it a slight 
arcuate opacity ; in cases, however, that are of especial intensity, per- 
foration of the cornea may occur. 

The complications above mentioned are observed only in severe 
cases— that is, only in ophthalmia catarrhalis. They very often owe 
their existence to faulty treatment of the catarrh. Among the laity, 
all sorts of household remedies are in use for inflammation of the eyes, 
such as the application of raw meat, or of bread soaked in milk, or of 
cooked onions, or a bathing with urine, etc. Such remedies are well 
adapted to increase the inflammation and produce complications. But 
even simple warm or cold compresses can have the same results. 

Etiology. — Atmospheric influences are the most frequent cause of 
catarrh. Their noxious influence makes itself felt more at certain 
seasous than at others, so that catarrh of the conjunctiva occurs with 
especial frequency at these times. For instance, this is the case in the 
spring, when so many people are attacked by catarrhs of the air pas- 
sages, by coryza, coughs, etc., and at the same time conjunctival catarrhs 
too are generally present in especially great number. At this time real 
epidemics of conjunctival catarrh occur, and under these circumstances 
it is the violent form (ophthalmia catarrhalis) which is prevalent. Dur- 
ing such an epidemic, contagion, effected by a transmissioQ of the secre- 
tion from one individual to another, plays a part in spreading the 
disease. This can occur, especially among children belonging to one 
family, by the indiscriminate use of towels, handkerchiefs, etc. 

Therapy. — By suitable treatment the duration of a conjunctival ca- 
tarrh can be considerably shortened and the development of a chronic 
catarrh prevented. The sovereign remedy in all the more intense cases 
of catarrh is the cauterization of the conjunctiva with nitrate of silver. 
This should come into contact with the conjunctiva only, and not with 
the cornea. In applying it, we evert the lids so that their conjunctival 
surface looks forward. The latter is then brushed over with a two-per- 
cent solution of silver nitrate and the excess of the solution is quickly 
washed ofE with lukewarm water or with a weak solution of salt. We 
now find the surface of the conjunctiva covered with a delicate bluish- 
white pellicle. This is the superficial slough which the solution has 
produced. The immediate result of this procedure, which is called 
brushing the conjunctiva, is violent burning and marked irritation of 
the eye, an increase, in short, of all the inflammatory phenomena (stage 
of exacerbation). After this has lasted from a quarter to half an hour, 
according to the energy of our application, improvement gradually sets 
in. An examination of the eye at this time shows that the thin slough 
is separating and is being thrown off in the form of shreds. When this 
is completed, we find the eye paler and the patient feels relieved and 
much less annoyed by his catarrh than was the case before the applica- 



DISEASES OP THE CONJUNCTIVA. 47 

tion of the brush (stage of remission). This improvement lasts from 
half a day to a day, according to the intensity of the catarrh. Then 
the troubles gradually increase again (recrudescence). This is a signal 
for repeating the application. As a rule, it is sufiBcient to make the 
application once a day, and best in the morning. 

Beginners must particularly avoid making the apjjlication too ener- 
getically. If this has been done, the pain that follows the application 
lasts uncommonly long (for hours), and we find that even after a pretty 
long time, indeed even on the following day, the slough is still adherent 
in places. This is a proof that the sloughing process has penetrated 
too deeply. If, in spite of this, we should repeat the application, we 
would produce a progressively deeper and deeper sloughing of the tis- 
sue, and increase the inflammation instead of curing it. We must 
omit the application, therefore, as long as the slough is still adherent 
to any part of the conjunctiva. 

Persons who are not able to visit the physician every day can be 
allowed to instill the silver solution at home. Since by this method 
the remedy comes into contact with the cornea, we must choose a 
weaker solution {-^ to ^ per cent), which, of course, acts less energet- 
ically upon the conjunctiva. This way of employing the silver solution 
is therefore resorted to only as a makeshift in those cases in which 
treatment by means of the brush is inapplicable from extrinsic reasons. 
When ihe inflammatory phenomena have in the main disappeared, the 
silver solution is exchanged for collyria that act less energetically, those 
namely that are employed in chronic catarrh, to which subject refer- 
ence must therefore be made for details (see § 9). 

In addition to our medicinal treatment of conjunctival catarrh, we 
must not forget to enjoin upon the patient general rules for taking 
care of himself ; telling him to keep the eye clean by washing it with 
lukewarm water, and to avoid smoke, dust, and bad air in general, and 
recommending him instead to pass his time in the open air. He must 
also refrain from straining the eyes much, especially in the evening by 
artificial light. In consideration, too, of the possibility of the spread 
of the disease by contagion, of which there is always a chance, the 
patient must take care not to use the same wash basin, towels, etc., 
with other people. 

^ Catarrhal conjunctivitis, also called conjunctivitis simplex, is, like catarrh 
of the air passages, reckoned among the so-called refrigeration diseases (diseases 
produced by cold). This, according to our present lights, is to be understood as 
meaning that acute conjunctival catarrh is due to atmospheric influences, but 
only in the sense that morbific matter is brought to the conjunctiva through the 
atmosphere. Again, the direct transfer of morbific matter from a diseased eye 
to a sound one may be the cause of acute conjunctival catarrh, for, even though 
the contagiosity of this disease is but slight, the cases with abundant secretion 
are undoubtedly contagious. In the violent cases of ophthalmia catarrhalis, 
particularly in those that develop epidemically, there is found as the cause of 



48 DISEASES OP THE EYE. 

the disease a very small bacillus, first described by Koch, afterwards by Weeks. 
Lighter cases, especially those that are associated with eczema of the angles of 
the lids, are caused by a diplobacillus (Morax, Axenfeld). The pneumococcus 
has been found in cases of acute conjunctivitis in small children, rarely in adults ; 
and the streptococcus in cases of catawh accompanied by lesions of the lachry- 
mal sac (Morax). 

Similarly dependent upon atmospheric influences is that form of acute con- 
junctivitis which accompanies hay fever. This aSection, which is pretty fre- 
quent in certain countries, attacks individuals who are predisposed to it in 
the beginning of the summer, and makes itself apparent by fever and also by 
violent catarrhal inflammation of the conjunctiva and of the air passages. 

While the infection which, in all probability, excites the catarrh of the con- 
junctiva comes to the latter from without in most cases, there are also instances 
in which a poisonous principle circulating in the blood causes the conjunctival 
inflammation. This is the case in the conjunctival catarrh which accompanies 
mea.sles, and indeed often forms the first prominent symptoms of it (see § 18). 

From the clinical picture of acute conjunctival catarrh, as sketched above, 
we sometimes find variations forming what are described as special varieties of 
catarrh. Among these variations belongs the development of so- called /oZKc?es, 
which will be described more precisely in § 10. Another variety of catarrh is 
vesicular catarrh, in which the conjunctiva of the tarsus is covered with numer- 
ous minute elevations, looking as if fine sand had been scattered over a moist 
glass plate (Arlt) ; according to Mayweg what we have to do with here is very 
small follicles. A third variety of catarrh is that which is given the name of 
the pustular form. In this, flat elevations develop upon the conjunctiva bulbi, 
mostly near the margin of the cornea. These break down into pus on their sur- 
face, and in this way are formed grayish or yellowish ulcers with somewhat ele- 
vated base and of the size of a millet seed or more. These have a great 
resemblance to the eSlorescences occurring in conjunctivitis eczematosa (§ 17). 
The distinction between the pustular form of catarrh and conjunctivitis eczema- 
tosa consists in the fact that in the former the phenomena of catarjhal inflam- 
mation are present in the conjunctiva of the lids and of the region of transition, 
while in conjunctivitis eczematosa these divisions x>i the conjunctiva take little 
or no part in the inflammation. Many regard this form as a mixture of con- 
junctivitis catarrhalis and conjunctivitis eczematosa. And, as a matter of fact, 
we must take this view into consideration in our treatment to this extent that 
in the beginning of the disease the application of the silver solution ordinarily 
proves to be the best thing, but later, after the more violent inflammatory phe- 
nomena have run their course, calomel is of the most service. 

The three varieties of catarrh just named are seen chiefly in children or in 
adolescents. They occur only as an exception in adults ; in the latter, on the 
contrary, we encounter much more frequently the crescentic ulcers of the cornea 
that result from catarrh, which are but rarely observed in children. Several 
crescentic ulcers may be present in the same eye at different parts of the cir- 
cumference of the cornea ; nay, more, by their confluence an annular ulcer may 
be formed, completely encircling the cornea. In the latter case the annular 
opacity which is left has a great resemblance to the arcus senilis comese (see 
§ 37). In cases where such an annular ulcer has penetrated deeply, the very 
detrimental result of a permanent ectasia of the cornea has been observed. Fur 
the floor of the ulcer stretches, and consequently the margin of the cornea at the 



DISEASES OP THE CONJUNCTIVA. 49 

point where the ulcer is situated is pushed forward, so that the whole cornea 
assumes an oblique position. If the ulcer completely surrounds the cornea, the 
latter may give way before the intra-ocular pressure and move forward en masse. 
In this case the region of the cornea inclosed by the annular ulcer lies like a 
watch glass on top of the marginal portions of the cornea (keratectasia ex 
ulcere, § 48). 

Nitrate of silver, our most important remedy in catarrh, was first employed 
for inflammations of the conjunctiva by St. Yves in the last century, although 
it was in this century that it first found general acceptation. People had a 
natural dread of instilling so irritating a liquid as a nitrate-of-silver solution 
into a violently inflamed eye. In fact, in a perfectly sound eye this solution 
excites violent irritation of the conjunctiva, and it is quite possible to produce 
an artificial catarrh by too frequent application of it. How then does it happen 
that the nitrate-of-silver solution has such a beneficent action in conjunctival 
catarrh ? The delicate bluish-white pellicle which covers the conjunctiva 
directly after the application is due to coagulation of the albumin of the cells 
in the upper layers of the epithelium by the nitrate of silver, so that these 
layers become opaque and die. The escharotic process acts like an irritant 
which increases the existing hypersemia. This not only gives rise to an increase 
of the annoyance suffered (exacerbation), but also induces a transudation under 
the eschar, so that the latter is loosened and finally cast off. But when this 
takes place the micro-organisms contained in the upper layers of the epithelium 
are thrown off with the eschar and so eliminated from the eye. 

The silver solution finds an extensive application not only in catarrh, but 
also in other affections of the conjunctiva. In regard to it the following hints 
may be laid to heart : (a) Many physicians apply weaker or stronger solutions 
according to the effect which is to be obtained, but we can always succeed with 
a 2-per-cent solution, since we have it in our power to regulate the effect by 
making a light or a penetrating application with the brush. (J) The applica- 
tion should not be made at night, because the secretion, which is poured out 
more abundantly after the application, would be retained in the conjunctival 
sac by the closure of the lids in sleep. For the same reason the eye ought not 
to be bandaged immediately after the application, (c) Corneal ulcers do not 
constitute a contraindication for making the application ; on the contrary, they 
furnish a direct indication for it, in case they prove to be catarrhal ulcers. Only 
still greater care than would otherwise be necessary must be taken to prevent 
the caustic from coming into contact with the cornea, {d) If the treatment of 
the conjunctiva with the silver solution is kept up too long (for some months or 
a year), there is produced little by little a dirty-gray coloration of the con- 
junctiva, which never afterward disappears. This phenomenon, called argyrosis 
or argyria,* is caused by the fact that silver is deposited in the form of an 
oxide or an albuminate in tlie tissues of the conjunctiva (in its elastic fibers), 
and can never afterward be removed. Argyrosis is produced even more readily 
by the constant instillation of the silver solution than by the application of 
the brush, since in the former case the excess of the solution is not removed by 
being washed off, but remains in the conjunctival sac. This coloration of the 
conjunctiva is also observed when the conjunctiva is constantly exposed to the 
action of silver dust, as occurs, for example, in many of those who work in silver. 

* Prom Hpyvpos, silver. 



50 DISEASES OF THE EYE. 

In conjunctival catarrh, as well as in other affections of the conjunctiva, 
acetate of lead is also employed, partly as an astringent, partly as a mild caus- 
tic, and either under the form of a solution to be applied on compresses, by in- 
stillations, and by means of the brush, or under the form of an ointment. As 
long as the cornea is perfectly normal this remedy is without ill effect ; but as 
soon as a loss of substance (ulcer) exists in the cornea, there is formed, if the 
use of the remedy is continued, an intensely white, very disfiguring opacity at 
the site of the ulcer. This lead incrustation, as it is called, is caused by the 
impregnation of the tissues of the cornea with the lead salt, and can be re- 
moved from the cornea with difiiculty or not at all. For this reason it is best 
to employ the lead acetate as little as possible in the treatment of conjunctival 
diseases; the more so, because a sufficiency of other remedies is at our com- 
mand, with which we can accomplish the same results without danger. ' 

Bandaging the eye in catarrh, as in all diseases of the eye accompanied with 
profuse secretion, is to be avoided as much as possible, since by it the free exit 
of the secretion is obstructed. 



{i) Conjunctivitis Catarrlialis Chronica. 

9. Symptoms. — In chronic conjunctival catarrh the changes objec- 
tively perceptible are on the whole but slightly pronounced. A mod- 
erate degree of redness of the conjunctiva exists either over the tarsus 
alone or in the region of transition also. The conjunctiva is smooth 
and not swollen ; it is only in old cases that hypertrophy with thick- 
ening and a velvety appearance of the conjunctiva is developed. The 
secretion is scanty and makes itself chiefly apparent by a gluing to- 
gether of the lids in the morning. The whitish scum often found at 
the angles of the lids is produced by the lachrymal fluid being beaten 
up with the secretion of the Meibomian gland into a sort of foamy 
emulsion, as a result of the frequent blinking of the lids. The con- 
stant moistening of the skin at this spot often leads to the formation 
of excoriations. In many cases the secretion, instead of being in- 
creased, seems even to be diminished. In view of the fact that there 
is little or no increase in the secretion, several authors call many of 
these cases not by the name of chronic catarrh, but by that of hyper- 
£emia of the conjunctiva. 

In proportion to the insignificance of the objective symptoms, the 
greater is the attention that has to be paid to the complaints made by 
the patient — in fact, the subjective symptoms are generally so charac- 
teristic that the diagnosis of chronic conjunctival catarrh can easily be 
made from them alone. The discomfort of the patient is usually greatest 
at night. The heaviness of the lids, scarcely noticeable in the daytime, 
becomes at night so marked that the patients have difficulty in keep- 
ing the eyes open ; they have the feeling of being sleepy. A very an- 
noying sensation of there being a foreign body — like a speck of dust- 
in the eye, is produced by the scanty secretion which remains in the 
conjunctival sac in the form of mucous filaments, and if these fila- 



DISEASES OF THE CONJUNCTIVA. 5j 

ments lie upon the cornea the sight is interfered with, or rainbow colora 
make their appearance about a candle flame when looked at. Further 
unpleasant sensations of various kinds are described, as, for example, 
that the eyes burn and itch ; that they are dazzled by the light ; that, 
moreover, they are tired out quickly by working ; that they blink 
often, etc. In the morning the eyes are somewhat stuck together, or 
a little yellowish dried secretion is found to have collected in the inner 
angle of the eye. In other cases there exists an annoying sensation of 
dryness, and the eyes can be opened only with difficulty, the patient, at 
the same time, having the feeling as if the lids were stuck to the eye- 
ball because of the lack of moisture [catarrhus siccus). These troubles, 
so various in their nature, do not always by any means bear any defi- 
nite relation to the objective condition. We see the conjunctiva quite 
intensely reddened in many people without their complaining in the 
least ; while in others, who do nothing but annoy the physician with 
their expressions of discomfort, there are often scarcely any changes 
perceptible in the conjunctiva. 

Course. — Chronic conjunctival catarrh is one of the most frequent 
of ocular diseases, chiefly affecting adults, and especially persons some- 
what advanced in age. In old people it is almost the rule to find a 
light grade of chronic conjunctival catarrh, which is denominated senile 
catarrh. The duration of conjunctival catarrh is ordinarily a long one; 
many people suffer from it for a great part of their lives. The disease 
can lead to cowplications which in part produce irreparable changes. 
Among the most frequent complications is inflammation of the edges 
of the lids {Mei}]iaritis), resulting from the frequent moistening of the 
palpebral margins by the copiously secreted tears. As a further con- 
sequence of this wetting with the tears, the skin of the lower lid is 
attacked with eczema, or it becomes rigid and contracted, so that its 
free edge is no longer in perfect apposition with the eyeball. As a 
result of this the punctum lacrimale no longer dips into the lacus lac- 
rimalis, so that the transportation of the tears into the lachrymal sac is 
impeded, the epiphora increased, and thus again a still further injuri- 
ous reaction upon the character of the skin is produced. In this way 
there is formed a vicious circle, which leads to a constantly increasing 
depression of the lower lid (ectropion). This outcome is still further 
promoted by the circumstance that the patient keeps wiping away the 
overflowing tears, and thus makes stroking movements from above 
downward, by which the lower lid is drawn down. If the contraction 
of the skin of the lids which have been moistened by the tears is more 
pronounced in the horizontal direction, blepharophimosis is developed 
(§ 112). Lastly, small ulcerations of the cornea are among the fre- 
quent products of catarrh. 

Etiolo^.— The causes which lie at the foundation of chronic catarrh 
are— 1. A preceding acute catarrh, which, instead of healing com- 



52 DISEASES OP THE EYE. 

pletely, passes into the chronic stage. 2. General injurious influences 
of various kinds. Chief among these is bad air, vitiated by smoke, 
dust, heat, the presence of many people, etc. Workers in factories 
where dust prevails largely, waiters in inns that are filled with smoke, 
etc., very frequently suffer from chronic conjunctival catarrh. Going 
late to bed, being up at night, and the immoderate use of alcoholic 
beverages are additional predisposing factors. Persons who already 
suffer from chronic conjunctival catarrh find that the latter is made 
considerably worse after the action of any injurious influence of this 
sort — for example, after an evening spent at the theater or in a smoky 
place. So also the constant action of wind and bad weather frequently 
causes catarrh in farmers, coachmen, etc. For the same reason, too, 
eyes which are very prominent (goggle eyes), or whose lids are re- 
tracted (lagophthalmus), are attacked by catarrh, because they are too 
little protected against the air. The effect which constant contact 
with the air exerts upon the conjunctiva is best shown in ectropion, 
where the conjunctiva tarsi, as it lies bare, becomes very much red- 
dened and thickened, and velvety or even covered with large promi- 
nences. The conjunctiva bears continued exclusion from the air as 
little as it does constant contact with it, on which account chronic 
catarrh sets in when bandaging of the eye is kept up for a long time. 
3. Excessive straining of the eyes, especially in hypermetropic or astig- 
matic persons can result in chronic catarrh. 4. Local injurious influ- 
ences. Here belongs irritation of the conjunctiva by foreign bodies 
lodging in the conjunctival sac, among which, using the term foreign 
bodies in the wider sense of the word, are to be reckoned cilia which 
are turned in toward the eye. In most cases the local injurious 
influence consists of some other disease of the eye, that induces 
catarrh as a sequela, as, for example, blepharitis or infarction of the 
Meibomian glands. Accumulation of the tears, as a result of blen- 
norrhoea of the tear sac, or because the punctum lacrimale does not 
dip properly into the lacus lacrimalis, is a frequent cause of catarrh, 
so that we should never forget to look for an affection of the tear 
passages in unilateral catarrh. We say unilateral, for catarrh produced 
by local causes is distinguished from that due to general injurious in- 
fluences in this respect, that the former is very frequently unilateral, 
while in the latter, from the nature of the case, both eyes are generally 
affected. 

Therapy. — It is clear that treatment must first of all pay regard to 
the causal factor by regulating in a suitable way, as far as is compatible 
with the patient's calling, the general conditions under which he lives 
and by removing all local causes of catarrh that may be present, etc. 
For the treatment of the conjunctiva itself we first employ, as we do 
in acute catarrh, the nitrate of silver, which is used either for applica- 
tion by the brush (in 3-per-cent solution) or for instillation (in i- to -^- 



DISEASES OP THE CONJUNCTIVA. 53 

per-cent solution). We make use of it in those cases only in which 
the catarrh is accompanied by rather abundant secretion and by re- 
laxation of the conjunctiva— that is, in periods of acute exacerbation, 

such as frequently occur in the course of every chronic catarrh and 

use it, furthermore, when hypertrophy of the conjunctiva has already 
set in. Otherwise we succeed better with astringent coUyria, which 
the patient can himself instill. The most usually employed of these 
are: The collyrium astringens luteum * or tinctura opii crocata, which 
are not ordinarily prescribed undiluted, but mixed with an equal quan- 
tity of water ; lapis divinus f and sulphate of zinc, both in ^- to 1-per- 
cent solution; also alum, tannin, boric acid,, and other astringents. 

The order in which these collyria are here arranged about corre- 
spond to their gradation in activity from the strongest to the mildest. 
They should be instilled once or twice a day, but not 'at night. So 
many of them are enumerated, because it is good to have a pretty 
large number to select from, since, if the catarrh is of long duration, 
a change will have to be made pretty often in the remedies. Every 
remedy, if too long applied, loses its activity, since the conjunctiva 
grows accustomed to it. For the sticking together of the lids, as 
well as for any excoriations that may be present, an ointment of 
white precipitate (|- to 1 per cent) may be rubbed upon the closed 
lids at night before going to bed. 

(c) Conjunctivitis Folliciilaris. 

10. Follicular catarrh is characterized by the presence of follicles. 
These are small round granules of about the size of a pin's head, which 
lie in the region of transition of the conjunctiva. They are of a pale, 
translucent aspect and puff up the conjunctiva in the form of small 
eminences. Either a few follicles only or many are present; in the 
latter case they are ordinarily arranged in rows like the beads of a 
rosary. Mici'oscopic examination shows that the follicles, as well as 

* This collyrium, called also Horst's eye water, is at present no longer official 
in most countries; yet it is of the greatest service, and in many oases can be re- 
placed by no other. According to the new (seventh) edition of the Austrian Phar- 
macopoeia, which went into effect on the 1st of January, 1890, it is to be prepared 
in the following way : 

Take of ammonium chloride 50 centigrammes and zinc sulphate 125 centi- 
grammes, dissolve in 200 grammes of distilled water, and add a solution of 40 centi- 
grammes of camphor in 20 grammes of dilute alcohol, and 10 centigrammes of 
saffron. Digest for twenty-four hours with frequent agitation, and filter. 

Romershausen's eye water, which is also frequently employed in chronic oph- 
thalmic catarrh, consists of a mixture of aqua foeniculi and tinctura fceniculi. 

[f Or aluminated copper; a preparation made by fusing together 33 parts each 
of copper sulphate, potassium nitrate, and alum, and adding a mixture of 2 parts 
each of camphor and alum. — D.] 



54: DISEASES OP THE EYE. 

the so-called trachoma granules, consist of a circumscribed accumula- 
tion of adenoid tissue (Fig. 26, T). 

Follicles are most frequently observed in youth, and can accompany 
both acute and chronic catarrh. Their significance consists in the fact 
that when follicles are present the malady is a protracted one. In 
chronic cases, the follicles remain stationary in the conjunctiva for a 
series of years. The follicles ultimately disappear without leaving a 
trace behind ; the disease, therefore, in spite of its long duration, has a 
good prognosis, in that it is cured without leaving any sequelee. In 
this particular, follicular catarrh is essentially distinguished from tra- 
choma, which in its external appearance bears a great resemblance to 
it,' but which, however, always leads to permanent changes in the con- 
junctiva. 

The etiology of follicular catarrh has not up to this time been 
established. By some, contagion, by others, miasm (vitiated air), has 
been assigned as a cause of the disease, without any certain proofs 
being brought for either one view or the other. The malady is found 
with especial frequency in schools, boarding establishments, etc., in 
which often many scholars are attacked by it at the same time. In 
many of these people the disease exists in an entirely latent way, as, in 
spite of there being a considerable number of follicles, the conjunctiva 
is not reddened and causes no sort of discomfort, so that the affection 
is first discovered by the physician's examination. 

The treatment is the same as we are accustomed to employ against 
conjunctival catarrh in any case. By means of it the inflammatory 
symptoms on the part of the conjunctiva and along with them the 
annoyance suffered are relieved ; but the follicles themselves generally 
remain obstinately stationary. In order to make them disappear, the 
best thing is to rub a lead ointment (acetate of lead 0.1-0.2 grammes, 
fatty matter 5 grammes) into the conjunctival sac. In doing this it 
must not be forgotten that the presence of corneal ulcers very strongly 
contraindicates the use of a lead ointment. Cases in which the folli- 
cles exist without causing any annoyance are best left without any treat- 
ment, As in catarrh of all kinds, so especially in follicular catarrh, 
living in fresh, pure air is to be recommended. 

II. CosrjuNCTivms Blennorrhoica Acuta. 
11. Acute Mennorrhcea* is an acute inflammation of the conjunc- 
tiva, which originates in contagion from gonorrhoeal virus, and whose 
copious purulent secretion is likewise contagious in its action. The 
carriers of the contagion are micro-organisms, namely, the gonococci 
discovered by Neisser. They bear this name because they also occur 
in the secretion of gonorrhoea. The gonococci are found both in the 

* Prom fi\4yya, mucus, and (i4a>, I flow. 



DISEASES OP THE CONJUNCTIVA. 55 

pus secreted by the conjunctiva and also in the most superficial layers 
of the conjunctiva itself. They are mostly arranged in pairs, as diplo- 
cocci, and as a rule lie together in heaps. Fig. 23 shows a specimen 
taken from the secretion of an acute blennorrhosa. In it are seen the 
heaps of gonococci, partly free {a), partly upon and within the cells, 
which are either pus cells (b) or cast-ofE epithelial cells (c). 

Acute blennorrhoea occurs both in adults and in newborn infants 
— blennorrhoea adultorum and blennorrhoea neonatorum. 



(a) Blennorrhoea Acuta Adultorum [Conjunctivitis Gonorrlioicd). 

Symptoms and Course. — When infection has taken place, the disease 
breaks out after a certain period of incubation, the duration of which 
varies according to the intensity of the contagious action from a few 
hours up to three days. The lids grow red, become hot, and are 
swollen with oedema, generally to such an 
extent that the patient can no longer open 
them, and even the physician often has 
trouble in separating them far enough from 
each other to bring the cornea into view. 
The conjunctiva of the lids and of the re- 
gion of transition is intensely reddened and 
greatly swollen. The swelling is produced 
by an abundant cellular infiltration of the 
conjunctiva, which is consequently tense, 
and has a granular, uneven surface. This 
feature of acute blennorrhoea serves to dis- 
tinguish it from catarrh, in which even in 

5 ' . . Fig. 23.— Secretion of Acute 

the severe cases the swelling is rather of a blenngerhiea with gonococci. 
serous nature, and hence the conjunctiva is 

yielding and has a smooth surface. The conjunctiva of the eyeball 
shows a like swelling, which stops short at the corneal margin, so that 
a raised wall is thus formed about, the more deeply placed cornea 
(chemosis). The secretion produced by the conjunctiva is like meat 
juice— that is, it is a serum which is colored red by admixture with 
blood, and in which float some flakes of pus. The eye is uncommonly 
sensitive to contact, the lymphatic gland in front of the ear is swollen, 
the patient has slight fever. 

Ordinarily it takes from two to three days for the disease to mount 
from its initial point to the pitch just described, and at this pitch it is 
maintained for two or three days more. This period is designated as 
the first stage, or stage of infiltration. Succeeding this as a second 
stage is that of pyorrlma. The swelling of the lids gradually dimin- 
ishes, a fact which we recognize principally by means of the return of 
the small wrinkles of the skin of the lids, and the tense infiltration of 




56 DISEASES 0¥ THE EYE. 

the conjunctiva slowly retrogrades. Simultaneously with this there be- 
gins a very profuse secretion of pus, which trickles out continually from 
the palpebral fissure ; hence the name pyorrhcea, or flow of pus. In 
the further course of the disease the swelling of the conjunctiva keeps 
on constantly diminishing, the eye, in many cases, returning to the 
normal state within the next four or six weeks. In most cases, how- 
ever, a condition of chronic inflammation of the conjunctiva remains, 
which is designated as the third stage of the disease, the stage of 
chronic Uennorrhma. In this period the lids are no longer swollen. 
The conjunctiva is reddened and thickened, especially upon the tarsus, 
where its surface looks uneven, granular, or velvety. The fold of tran- 
sition forms an ungainly swelling; the conjunctiva of the eyeball, 
which shows hypereemia only, is the least changed. After this state of 
conjunctival hypertrophy has abated, a process which usually takes 
months for its accomplishment, there usually remain slight, but perma- 
nent cicatrices of the conjunctiva. 

The description here given corresponds to cases of most frequent 
occurrence, which are those of medium intensity. In addition, both 
light and also very severe cases of the disease come under observation 
which exhibit rather different features. In the light cases, which we 
are accustomed to call suiacute hlennorrlima, all the inflammatory 
changes are less, and the changes are limited chiefly to the conjunctiva 
of the lids. Such cases are frequently not to be distinguished with 
certainty by their external aspect from violent catarrh. The diagnosis 
can be rendered certain by the microscopic examination of the secre- 
tion, since by it the presence or absence of gonococci is demonstrated. 

In the severest cases, the infiltration of the conjunctiva is so great 
that the latter in places appears no longer red, but grayish-yellow, be- 
cause, as in diphtheritic disease of the conjunctiva, the vessels are com- 
pressed by the bulky exudation, and the conjunctiva is thus rendered 
anaemic. The conjunctiva forms about the cornea a tense grayish-red 
wall. Quite often the surface of the conjunctiva is found to be cov- 
ered with a clotted exudate, or croupous membrane. 

The most dreaded complication of acute blennorrhoea is the involve- 
ment of the cornea, by which, in many cases, incurable blindness is 
produced. At first the cornea becomes dull upon its surface and cov- 
ered with a slight difiused opacity. Then circumscribed infiltrations 
of grayish color make their appearance, which soon become yellow and 
break down into ulcers. These infiltrations may be situated at the 
margin of the cornea, and give rise to speedy perforation of the latter. 
This is a comparatively favorable result, as, after the perforation has 
taken place, the purulent infiltration of the cornea is not rarely brought 
to a standstill, and so a portion of the cornea is preserved. But it can 
also happen that the mprginal infiltrations become rapidly confluent, 
and unite into a yellow ring surrounding the entire cornea (a so-called 



DISEASES OF THE CONJUNCTIVA. 



57 



annular abscess). In that event the cornea is lost, for this ring soon 
spreads over the entire cornea and destroys it. In other cases the 
purulent disintegration occurs first in the middle layers of the cornea. 
A rare and peculiar form of involvement of the cornea occurs, in which 
the latter, without becoming noticeably opaque, melts away, as it were, 
like a piece of ice in the sun, until it has disappeared altogether, with 
the exception of a narrow portion of its rim. When, in one way or an- 
other, the cornea has gone either entirely or in part to destruction, 
cicatrices are formed with incarceration of the iris, or pauophthalmitis 
itself may be produced. Since these sequelae are observed after every 
destruction of the cornea, even when due to other causes, they will find 
detailed description under the diseases of the cornea. 

Involvement of the cornea is so much the more to be expected, the 
severer the blennorrhcea, and, in particular, the more pronounced the 
participation of the conjunctiva bulbi in the inflammation. In the 
severest cases with tense chemosis the cornea is always affected, and is, 
as a general thing, irretrievably destro3'ed. In the cases of moderate 
severity, when the chemotic swelling of the conjunctiva is less pro- 
nounced and especially is less hard, it is usually possible to preserve the 
' cornea, either entirely or in great part, inasmuch as the ulcers that de- 
velop, even if they are attended with perforation, are of but small size. 
In the lightest cases, where the process is limited to the palpebral con- 
junctiva, there is, on the whole, little danger to the cornea. 

The severer the course of the inflammation, the earlier the involve- 
ment of the cornea sets in; in violent cases, the cornea is already 
clouded by the second or third day. Sometimes corneal ulcers are 
not developed until late in the disease, when the blennorrhrea is 
already well on the retrograde path. These late affections of the 
cornea are not very dangerous, and it is generally possible to check 
them readily. 

The prognosis of the disease results from what has been said, it 
being essentially founded upon the condition of the cornea. This is 
dependent upon the intensity of the inflammation of the conjunc- 
tiva bulbi, in accordance with which, therefore, the prognosis must 
be made. 

Etiology.— Acute blennorrhcea is produced simply and solely by 
infection. The poison can be introduced into the eye from the genitals 
directly, generally by an individual (whether man or woman) affected 
with gonorrhoea, touching the eyes with unclean fingers after these 
have been in contact with the genitals. The infection, however, can 
also come from an eye affected with blennorrhcea. If, for instance, 
one eye is already diseased and is affected with profuse suppuration, 
the other eye also can be infected by a transfer of the secretion to 
it. An individual with an eye diseased with bleunorrha?a can infect 
the persons who are nursing him or any others who may share his 



58 DISEASES OP THE EYE. 

room, so that we sometimes see an entire family stricken with this 
baneful malady. 

Therapy. — By proper prophylaxis infection by acute blennorrhcea 
can be prevented, a matter to be so much the more considered because, 
when the disease has once broken out, an unfortunate result can not 
always be averted. It is the physician's duty to call the attention of 
every man with gonorrhoea, and also of every woman with a vaginal 
discharge, to the danger of infecting the eyes, and to urge upon them 
strenuously the requisite cleanliness. If the eye is already attacked 
with acute blennorrhcea, care must be taken to keep the othfr eye 
from being infected by it and also to keep the disease from being 
transferred to persons in the vicinity. The protection of the second 
eye which has not as yet been involved in the disease is best effected 
by a bandage which is applied in the following manner : The palpebral 
fissure is first closed by means of some narrow strips of sticking plaster 
applied in a vertical direction. Then the hollow about the eye is 
filled up with cotton, and the whole is covered by a flap of linen pro- 
vided with adhesive-plaster strips, which is carefully attached all round 
the margins of the orbit. In order to secure it better, the edges of the 
flap and the adjacent skin may further be coated with collodion. To 
prevent the spread of the disease to those in the neighborhood of the 
patient, the greatest cleanliness must be inculcated both upon him and 
upon the persons attending to him ; they must always cleanse the 
hands after touching the affected eye, and must remove, or, best of all, 
burn, all materials that have been used for cleansing the eye (pieces of 
linen, cotton, etc.). 

The treatment of the disease itself consists principally in a careful 
and frequently repeated cleansing of the eye from its profuse secretion. 
We may employ for this purpose weak antiseptic solutions (solution of 
corrosive sublimate, 1-4,000, or of potassium permanganate). If the 
great swelling of the lids does not permit the palpebral fissure to be 
properly opened, and thus makes cleansing impossible, the palpebral 
fissure must be fully widened by a section made with the scissors at 
the external angle of the lids (canthoplasty ; see § 168). This section 
has the further advantage of diminishing the pressure which the much- 
swollen lids exert upon the eyeball. 

In the first stage of the disease we combat the inflammation by 
iced compresses, and also by the application of leeches (six to ten in 
number) to the temple. In the second stage brushing the conjunctiva 
with nitrate of silver is the best means for making the swelling of the 
conjunctiva and the profuse secretion rapidly disappear. The appli- 
cation of the brush must not, however, be begun until the tense swell- 
ing of the conjunctiva has given place to a soft, succulent condition ; 
there should no longer be any membranous deposit, any grayish infil- 
trated spots upon the conjunctiva. The application should be made 



DISEASES OF THE CONJUNCTIVA. 59 

with a two-per-cent solution, but quite freely, and must be repeated 
twice a day as long as the profuse secretion is still present. The pres- 
ence of ulcers of the cornea furnishes no contraindication to the use of 
nitrate of silver. 

As soon as, in the third stage, the inflammatory symptoms and the 
secretion also have nearly disappeared and the thickening of the con- 
junctiva is the only thing that still remains to be removed, we exchange 
the silver solution for copper sulphate. This is applied by whittling a 
crystal of the substance down to a smooth, rounded extremity (copper 
pencil or bluestone) and stroking with it once or more the conjunctiva 
of the everted lids. Then the lachrymal fluid, which is tinged blue by 
the copper salt dissolved in it, is dipped up from the conjunctiva with 
a pledget of cotton ; otherwise the pretty concentrated copper solution 
would come into contact with the cornea and irritate it greatly. The ap- 
plication of the bluestone is much more painful than that of the silver 
solution, but acts more energetically, and hence we get quicker results 
with it ; but this treatment is permissible only if the cornea is either 
quite sound or has ulcers already in process of cicatrization, and not if 
there are fresh ulcerations of the cornea, which are still coated with pus. 
The treatment of ccmplications involving the cornea is conducted 
according to the rules (§§ 34, 36) for purulent keratitis. If very 
severe, all treatment proves powerless to preserve the cornea, so that 
we must confine ourselves to attempting to avoid the more remote evil 
consequences of destruction of the cornea, like panophthalmitis or the 
formation of staphyloma, and to obtain a flat cicatrix. 

It is now established beyond doubt that acute blennorrhoea is developed 
by the direct transfer of virulent pus to the conjunctiva. The earlier view, 
which explained the connection between gonorrhoea and ophthalmia by looking 
upon the latter as a sort of metastasis of gonorrhoea, has now no longer any 
adherents. Nevertheless, cases have been described recently (by Ricord, Roos- 
brock, HaltenhoS, Rilckert, Armaignac, and others) in which a conjunctival 
inflammation of a lighter kind is connected with a gonorrhoea in the way of 
metastasis, just as arthritis and iritis sometimes complicate a gonorrhcEa. This 
metastatic mode of origin is to be understood by supposing that the gonorrhoial 
poison has got into the circulation, and is exciting inflammation in remote 
organs which have a predisposition for this poison. A conjunctivitis originat- 
ing in this way is said to show the characters, not of a blennorrhoea, but of a 
violent catarrhal conjunctivitis, and the injection of the eyeball is like that 
which occurs in scleritis. In any case, we shall have to be uncommonly careful 
in making the diagnosis of such a metastatic gonorrheal conjunctivitis, since 
light cases of conjunctivitis can also develop from direct infection with gonor- 
rhoeal secretion, in case the gonorrhoeal poison has been weakened by various 
circumstances. (See infra, the investigations of Piringer.) As a gonorrhoea of 
the urethra can by metastasis excite a conjunctivitis, so also conversely oases 
have been observed in which a gonorrhoeal arthritis, where gonococci have been 
demonstrated to exist in the pus, has arisen by way of metastasis from a blen- 
norrhoea of the conjunctiva (Deutschmann and others). 



60 DISEASES OP THE EYE. 

The secretion containing gonooocci is usually brought into the eye by means 
of dirty fingers. Sometimes, however, a direct transfer from the diseased mu- 
cous membrane to the sound one is observed ; for example, when a drop of secre- 
tion spurts into the eye of the physician or the attendant while cleansing geni- 
tals that are affected with gonorrhoea, or even when cleansing the eye of a patient 
affected with blennorrhoea. For this reason the old method of cleansing blen- 
norrhoeal eyes by means of a glass syringe has been given up in most ophthalmic 
clinics, as it endangers both the eye of the patient and the eyes of the corps of 
attendants. Furthermore, in the treatment of such patients, physicians and at- 
tendants ought always to use protective glasses (large, colorless coquille glasses). 
If, in spite of this, any secretion does spurt into the eye, the latter must im- 
mediately be very thoroughly washed out; then a couple of drops of two-per- 
cent nitrate-of-silver solution instilled, and subsequently for some hours cold 
compresses placed upon the eye. 

I have repeatedly seen cases in which a patient, because of a mild conjunc- 
tival catarrh, washed his eyes in his own urine (a popular remedy among the 
laity in many places); as he had gonorrhoea, he acquired an acute blennorrhoea. 
Acute blennorrhcea, moreover, has been seen to originate from the use of an- 
other household remedy— that is, from the practice of laying upon the eye a 
piece of placenta, which in this case came from a woman affected with gonor- 
rhoea. 

If one eye is already infected, the transfer to the other is often brought 
about by the secretion of the diseased eye flowing over the bridge of the nose 
into the sound eye during sleep. Furthermore, the secretion can be transferred 
from the eye affected with blennorrhcea to the sound one by the finger, the 
water used for washing, the sponge, the handkerchief, etc. For these reasons 
the sound eye should be bandaged. If there is ground for suspecting that in- 
fection has already taken place, we can endeavor to prevent the outbreak of the 
disease by instilling a two-per-cent solution of nitrate of silver before applying the 
bandage. In order that the patient may see with the bandaged eye, we can 
insert a watch glass in an aperture which v^e make in the middle of the bandage. 

The transfer of blennorrhoea from an eye affected with the latter to the eyes 
of other people is likewise not rare. It occurs most frequently in children 
who are affected with blennorrhoea neonatorum, and thus infect their mothers, 
nurses, etc. In the Vienna Foundling Asylum, during the years 1812 and 1813, 
there were, for every hundred infants affected with blennorrhcea, more than 
fifteen nurses so affected, who had acquired their eye disease from the in- 
fants. I have seen a whole family infected with blennorrlioea by a child hav- 
ing blennorrhoea neonatorum, and thus plunged in the greatest misery. Great 
caution on our own part, therefore, and, what is more important, careful instruc- 
tion of the laity are here imperatively required. 

"We sometimes also observe acute blennorrhaa in small girls of the age of two 
to ten years, who at the same time are troubled with a vaginal discharge (Arlt). 
Here are we still dealing with contagion from a virulent vaginal catarrh ? or is 
the vaginal discharge of these girls a benign catarrh caused by scrofula, anaemia, 
and the like ? In some of these cases it has been possible to prove the origin 
of the vaginal blennorrhcea. The children have acquired the latter from their 
mothers or from other women about them, who were suffering from virulent 
vaginal catarrh, and had transmitted the latter by soiled clothes, sponges, 
baths, etc., to the children (Hirschberg). In other cases, the children had been 



DISEASES OP THE CONJUNCTIVA. gi 

raped by individuals affected with gonorrhoea. Here, therefore, we are dealing 
with a pure vagina! gonorrhoea in the children, and, accordingly, it is possible in 
such cases, too, to demonstrate the presence of the gonococcus both in the secre- 
tion of the. vagina and in the conjunctiva as well (Widmark). But it would be 
going much too far to regard the vaginal discharge in little girls as true gonor- 
rhoea in all cases in which infection of the conjunctiva results from the dis- 
charge. It seems to me probable that even a non-virulent, simple catarrhal 
secretion of the vagina is in position to excite an inflammation of the conjunc- 
tiva, which in this instance runs a less severe course, and exhibits the character 
of a mild (subacute) blennorrhoea. The distinction from a true blennorrhcea 
could be made in this case only by the microscopical examination of the secre- 
tion for gouococci. 

The interesting researches of Piringer have instructed us in regard to the 
relation letween the infective material and the ophthalmia produced hy it as 
he has made a great number of intentional transfers of virus (generally in the 
eyes of people already blind, who were paid for the experiment). He found 
that the period of incubation is of shorter duration in proportion as the blennor- 
rhoea which the inoculated material produces is more violent. The infective 
power of the secretion is weakened by various influences, as by dilution with 
water— by dilution to the one-hundredth part any secretion can be rendered 
inert— or by drying. Secretion that has been dried upon a piece of linen loses 
its activity after thirty-six hours. Preserved like vaccine, it remains infective 
for sixty hours. In proportion as the virulence of the infecting secretion is 
weakened, the period of incubation increases in length and the inflamma- 
tion excited grows milder. The differences that we observe in the grades of 
blennorrhoea can therefore be referred to the fact that the source of infection 
supplies secretion of different degrees of virulence, and this virulence is, more- 
over, still further modified by the immediate circumstances attending the process 
of infection. That the lymphatic gland in front of the ear should swell up in 
acute blennorrhoea is a fact that accords with the virulent character of the latter; 
sometimes even suppuration of this gland has been observed (bubo prscauricularis). 

The purulent inflammation of the cornea, which so often complicates the 
blennorrhcea, is to be referred to infection of the cornea by the secretion which 
constantly bathes the latter. Since the secretion collects most of all in the 
gutter lying at the rim of the cornea, between the latter and the steep slope of 
the chemotic conjunctiva, the purulent infiltration most frequently begins here, 
too. The dense infiltration existing in this chemotic wall of conjunctiva is to 
be regarded as a second factor in the production of corneal trouble. This leads 
to obstruction of the circulation in the marginal loops of the cornea, and thus 
interferes with the nutrition of the latter. Hence, the more pronounced and the 
more tense the chemosis, the more confidently is an affection of the cornea to 
be anticipated. It is in harmony with this fact that, in cases where the chemo- 
sis is unequally great, we often see the involvement of the cornea take place 
first at that portion of the corneal rim where the chemosis is the greatest. 

Since infection of the cornea is certainly very greatly favored by the exist- 
ence of gaps in the epithelium of the latter, we must avoid injuring the epi- 
thelium of the eye by carelessness in cleansing. 

If acute blennorrhoea happens to affect an eye which is covered with pannug 
the latter will afford the cornea a secure protection against suppuration. Nay, 
more, it is often apparent, after the violence of the inflammation has passed, 



62 DISEASES OP THE EYE. 

that the pannus has cleared up considerably, so that- in cases of old pannus 
inoculation with acute blennorrhoea has been designedly performed. 

The fact that acute blennorrhoea is produced by micro-organisms would 
lead us to expect that disinfectant substances would be the best remedies in the 
treatment of it. Nevertheless, it has been shown that nitrate of silver far sur- 
passes the disinfectants proper for this purpose. It is, in fact, specially poi- 
sonous to the gonococcus, and, moreover, effects its removal mechanically by 
reducing to an eschar, and thus leading to the exfoliation of, the superficial 
layers of epiihellum containing this microbe. 

In the first stage of the disease we may make use of scarifications of the 
chemotic conjunctiva in severe cases. 

(5) Blennorrhma Neonatorum. 

12. This disease is identical with the blennorrhcea of adults. More- 
over, it owes its origin to infection by secretion from genitals which 
are afEected with virulent catarrh. The infection occurs as a rule dur- 
ing parturition. In the passage of the child's head through the vagina, 
the eyelids are covered with the secretion of the latter, and this either 
penetrates immediately into the conjunctival sac through the palpebral 
fissure, or does so as soon as the child opens his eyes for the first time. 
Under these circumstances the disease breaks out as a rule on the sec- 
ond or third (rarely on the fourth or fifth) day after birth. In those 
cases in which the disease makes its appearance still later than this, 
the infection can not any longer be referred to the act of birth. It 
has then been brought about through subsequent infection by the 
vaginal secretion of the mother (as is readily possible, particularly if 
the child sleeps in bed with the mother), or the child has been in- 
fected by another child, as, for instance, not rarely happens in lying-in 
establishments and foundling asylums. 

The symptoms of the disease are the same as in the blennorrhcea of 
adults, except that they are in general less severe. For even when 
there are great swelling of the lids and very profuse purulent discharge, 
the part which the bulbar conjunctiva takes in the process is relatively 
small, and we rarely find great chemosis. Hence also the danger of 
suppuration of the cornea is not so great. It does indeed occur, and 
that often enough too, but only in those cases which are treated badly or 
not at all. If a case comes under treatment in season — that is, while 
the cornea is still intact — the latter can almost to a certainty be main- 
tained in a healthy state. Supposing this condition to be fulfilled, 
therefore, the prognosis can be stated as favorable. 

The treatment in the first stage consists in diligent cleansing of the 
eye ; when suppuration commences we begin with the application of a 
two-per-cent nitrate-of-silver solution to the conjunctiva. In cases 
with profuse secretion this must be done twice a day. The application 
should be continued until the cure is complete, as otherwise it is easy 
for the process to recur to a moderate degree. 



DISEASES OP THE CONJUNCTIVA. 



63 



In blennorrhoea of the newborn, prophylaxis plays an even greater 
role than in the blennorrhoea of adults. There is perhaps no other 
disease in which the rigorous carrying out of prophylactic treatment 
would afford more gratifying results than in blennorrhcea of the new- 
born, which might In this way be made to disappear almost entirely. 
The principle which lies at the foundation of prophylaxis is the avoid- 
ance of infection during parturition. To this end the vagina should 
be cleansed as well as possible by antiseptic injections directly before 
parturition, a procedure which is also advisable on other grounds. 
As soon as the child is born, the lids while still closed are to be 
wiped off carefully with a clean rag. While the first bath is being 
given the child's eyes should not be wet with the water of the bath. 
As soon as the child has been wrapped up after the bath, the eyes 
should again be cleansed with clean water and with a piece of cloth or 
cotton designed for this purpose expressly, and then a drop of two-per- 
cent silver solution dropped into each eye. By this procedure, which 
was devised by Orede, blennorrhoea of the newborn can be avoided 
almost to a certainty. 

Blennorrhcsa of the newborn belongs among the diseases of frequent 
occurrence. The majority of pregnant women have catarrh of the vagina with 
a mucous or purulent discharge. In the greater portion of these cases we have 
to do with a benign vaginal catarrh, in a smaller portion with a virulent catarrh 
(gonorrhrea). In individual cases the distinction between benign and virulent 
is diiScult or impossible, for which reason prophylactic treatment ought to be 
carried out in all cases. 

The frequency of ophthalmia among the children, before the introduction of 
prophylactic treatment, varied from one to twenty per cent in different lying-in 
establishments. Among these are comprised light and severe cases. In the 
former, ordinarily no gonococci are found in the secretion, although pneumo- 
cocci are often present (Parinaud, Morax); these cases are hence not to be 
regarded as blennorrhoea. Conjecturally these are the cases in which the 
mother has a benign catarrh of the vagina. Of the severe cases, those of blen- 
norrhoea proper, a certain number go blind on account of the failure to treat 
them in season, so that a very considerable number of cases of blindness are to 
be laid to the account of this disease. In the asylums for the blind of Germany 
and Austria, those who are rendered blind by blennorrhcea neonatorum form 
more than a third part of the whole number ; on the whole, those who are 
rendered blind in this way certainly constitute more than the tenth part of all 
living blind persons. The number of the blind in Europe is reckoned at more 
than three hundred thousand. If blennorrhcea neonatorum were made to dis- 
appear from the causes of blindness by universally carrying out a prophylactic 
treatment, there would be in Europe alone at least thirty thousand fewer blind 
people. 

That prophylaxis, as introduced into practice by Cred6, is actually efficient, 
is proved by the following data : Cred6 formerly had in the Lelpsic Lying-in 
Asylum on an average in the whole number of newborn 10.8 per cent of cases 
of blennorrhoea neonatorum ; after the introduction of his prophylactic method 
the number sank to 0.1 to 0.2 per cent. Others have similar favorable results 



64 DISEASES OP THE EYE. 

to record. Unfortunately, up to the present time, the prophylaxis of blennor- 
rhcea has not been generally introduced by law ; it has merely been brought into 
use in lying-in establishments and also in the private practice of many physi- 
cians, while to the vast majority of children it is not applied at all. 

Credo's prophylactic treatment acts as a protection against infection during 
parturition only. Infection can, however, take place even earlier : children 
have been known to come into the world with a blennorrhoea already fully 
developed— in fact, with the cornea already destroyed. Furthermore, against 
subsequent infection by the vaginal secretion of the mother, or by other chil- 
dren, other measures will have to be adopted, among which great cleanliness is 
to be assigned the first place. In foundling asylums, infants infected with 
blennorrhcea should, be isolated from the rest, as otherwise infection will fre- 
quently take place. In the Vienna Foundling Asylum, during the years 1854- 
'66, no less than fourteen hundred and thirteen children were first attacked by 
blennorrhcea while in the asylum, and hence caught the infection in the latter. 

In infants after the subsidence of the acute inflammation, a chronic hyper- 
trophy of the conjunctiva (chronic blennorrhoea) develops much less frequently 
than in adults. On the other hand, after severe cases of blennorrhoea neona- 
torum, the conjunctiva, especially in the retrotarsal folds, often acquires a deli- 
cately cicatricial character, which remains for life. 



III. Conjunctivitis Tkachomatosa. 

13. Trachoma, like acute blennorrhoea, is an inflammation of the 
conjunctiva, which originates by infection, and produces an infectious, 
purulent secretion. It is distinguished from acute blennorrhoea prin- 
cipally by its chronic course, in which is developed an hypertrophy of 
the conjunctiva, that forms the most characteristic symptom of tracho- 
ma. From the roughness of the conjunctiva, caused by this hyper- 
trophy, the disease has in fact received its name.* 

Symptoms. — The patients complain of sensitiveness to light, of lach- 
ryraation,and of sticking together of the lids; pain and visual disturb- 
ances are also often present. The examination of the eye shows that 
the latter is less widely opened, partly because of photophobia, partly 
because the heavy upper lid hangs lower down. After everting the 
lids, we see the conjunctiva of the tarsus and also that of the fold of 
transition reddened and thickened ; its surface at the same time has 
become uneven to a varying degree. These changes are to be referred 
to an hypertrophy of the mucous membrane, which occurs under two 
different forms. 

The first form consists in the development of the so-called papillee. 
These are elevations newly formed on the surface of the conjunctiva, 
which consequently appears velvety, or, if the papillee are large, ap- 
pears studded with coarse granules, with small nodules, or even with 
raspberry-like projections, the thickening of the conjunctiva being 

* Trachoma, from rpaxis, rough. 



DISEASES OF THE CONJUNCTIVA. g5 

so great that the subjacent Meibomian glands are no longer Tisible 
through it. This kind of hypertrophy, which is called the papillary 
form, is found exclusively in the tarsal conjunctiva (Fig. 24 A). It is 
always most clearly pronounced on the upper lid, which therefore 
must be everted in making the diagnosis of the trachoma. 

The second form of hypertrophy is characterized by the presence of 
the trachoma granules. These are gray, translucent, roundish bodies. 





Fig. 24,— Schematic Section throcgh the Lids and Eyeball {A, in Recent, B, in Old 

Trachoma). 

A shows the way in which the two forms of hypertrophy of the conjuiictiva are distributed 
among the separate divisions of the latter ; B, the stage of sequelse of trachoma ; s, Sj, 
eyebrows ; o, Oj, furrow between the brow and the lid (sulcus orbito-palpebralis) ; d, d,, 
covering fold ; c, cilia in their proper position ; c,, cilia turned toward the cornea ; r, free 
border of the lid, wath the borders of the upper and lower lids running yjarallel and the pos- 
terior margins of the lids acute ; rj, free border of the lid, looking backward, and with its 
posterior margin rounded ; t, tarsus thickened by infiltration and covered w-ith the velvety 
conjunctiva tarsi ; /j, tarsus thinned (atrophic), "bent at an angle near its free extremity, 
and covered with smooth epithelium ; /, fornix with numerous trachoma granulations, 3', 
in the folds of the conjunctiva ; /„ fornix smooth, without folds (symblepharon posterius) ; 
p, thick pannus covering the upper half of the cornea ; pi, a shrunken pannus, extending 
over the whole cornea. 

which push up the most superficial layers of the conjunctiva in the 
form of a hemisphere, and are visible through the conjunctiva. On 
account of their translucent, seemingly gelatinous character, they have 
been likened to the eggs of frog-spawn or to grains of boiled sago. They 
are found principally in the folds of transition (/, Fig. 34 A), in which 
they are imbedded in such numbers that, when the lower lid is drawn 
down, the fold projects as a thick, rigid swelling, at the summit of which 
we sometimes see the granules arranged in rows like a string of pearls. 
In the conjunctiva tarsi the trachoma granules are less readily visible. 
They are smaller in this situation, and can not push the conjunctiva 
up because the latter is very closely adherent to the tarsus. Here, 
5 



66 DISEASES OP THE BYE. 

therefore, they generally appear as small, bright-yellowish points, which 
are situated deeply in the mucous membrane ; quite often, though, 
they are hidden from sight altogether by the development of the pa- 
pillae. Trachoma granules are often found in the semilunar fold, 
more rarely in other parts of the conjunctiva of the eyeball. This 
variety of proliferation of the conjunctiva is called the granuiar form. 

The two forms of proliferation of the conjunctiva sometimes occur 
separately. In the great majority of cases, however, both are found at 
the same time in the same eye, and so distributed that in the conjunc- 
tiva of the lids the most prominent feature is the proliferation of pa- 
pilla3, in the fold of transition it is the formation of trachoma granules 
(Pig. 24 A). The conjunctiva of the eyeball is, in light cases, un- 
altered, but when the irritation is more intense shows a coarsely reticu- 
late injection. The conjunctiva discharges a purulent secretion, the 
quantity of which is more abundant in the fresh cases and iu those 
attended with marked symptoms of irritation. In older cases, on the 
contrary, and in those which run a more sluggish course, it is very 
scanty. 

The disturbance of sight, of which many patients complain, is 
founded upon a complication affecting the cornea, and appearing under 
two different forms, pannus and ulceration, which very frequently occur 
together. 

Pannus * tracJiomatosiis consists in the deposition upon the surface 
of the cornea of a newly formed, brawny, vascular tissue, which pushes 
its way from the edge toward the center of the cornea. At the spot 
where the pannus is located, the surface of the cornea is uneven and 
studded with fine projections, and there is a gray, translucent, super- 
ficially situated, cloudy mass, which is traversed by numerous vessels. 
The latter spring from the vessels of the conjunctiva, which pass 
over the limbus and out upon the cornea, and, after arriving within 
the pannus, branch in an arborescent fashion. The pannus ordi- 
narily begins its development at the upper margin of the cornea, and 
cover first the upper half of the latter (p, Fig. 24: A). Quite often 
it terminates below in a sharp, straight, horizontal border. After- 
ward pannus develops at other portions of the corneal margin, until at 
length the entire cornea is covered by it. When pannus is pretty fully 
developed, the iris likewise participates in the inflammation (iritis). 
Disturbance of vision sets in as soon as the pannus has advanced into 
the pupillary area of the cornea — that is, in that region of the latter 
which lies directly opposite the pupil. If this region is entirely cov- 
ered by pannus, vision is reduced until it is limited to the recognition 
of large objects, or even to the mere ability to distinguish between 
light and darkness (quantitative vision). 



* Pannus, a cloth. 



DISEASES OP THE CONJUNCTIVA. g-. 

The ulcers of the cornea either develop at a spot that is otherwise 
normal, or they occur in connection with pannus. In the latter case 
they are found principally at the free border of the pannus, more rarely 
within the latter. Since their character agrees with that of ulcers of 
the cornea generally, a more detailed account of them will be given 
under the latter head {§§ 32 et seq.). 

Course.— This is of the following character : 

The hypertrophy of the conjunctiva gradually increases, growing 
steadily greater, until it has reached a certain height, which is not the 
same in all cases. Then it disappears again, step by step, while a cica- 
tricial state of the conjunctiva with contraction takes its place. In 
this way the trachoma is cured in the sense that the specific morbid 
process has come to an end. Nevertheless, the conjunctiva has not 
become normal again by any means ; on the contrary, it bears upon it 
lasting marks of the disease that has passed, namely, the signs of a cica- 
tricial contraction which, in many instances entails other, additional 
consequences, such as we will group together under the phrase " the 
state of sequelae of traclioma." The more considerable the degree which 
the hypertrophy of the conjunctiva attains, the greater and more strik- 
ing is the contraction of the latter, and the longer, too, is the duration 
of the disease, which in most cases is counted by years. The object of 
the treatment, therefore, must consist in checking the hypertrophy of 
the conjunctiva while it is developing, as thus both the duration of the 
disease is shortened and its evil consequences also are reduced to a 
smaller amount. 

In the conjujictiva tarsi, the beginning of the formation of cica- 
trices is betokened by a few narrow, whitish striaj (fine cicatricial bands), 
which we see emerging in the midst of the reddened and thickened 
conjunctiva. These striae gradually become more numerous and unite 
to form a delicate network, the meshes of which are occupied by red is- 
lands — that is, by those portions of the conjunctiva which are still hyper- 
«mic and hypertrophied. Little by little the cicatricial lines grow stead- 
ily bi'oader and the islands that they inclose steadily narrower, until at 
length that condition is produced in which the conjunctiva of the tarsus 
has become perfectly pale, thin, and smooth. The cicatricial condition 
of the conjunctiva corresponds in extent and intensity to the amount of 
hypertrophy that has preceded it. In those cases in which the hyper- 
trophy of the conjunctiva has attained a considerable height in certain 
spots only, it is also only at these spots that deep cicatrices remain 
after the trachoma has run its course, while those parts of the conjunc- 
tiva which were simply infiltrated, or were hypertrophic to only a very 
slight degree, return to the normal state. 

In the conjunctiva of the fornix the same conversion of hyper- 
trophy into cicatricial contraction takes place. Only, the external 
phenomena are somewhat different, in conformity with the different 



68 DISEASES OP THE EYE. 

character of the conjunctiva in this situation. Here we do not see 
any whitish bands, but we find that the thick swellings which are 
formed by the hypertrophic fold of transition are becoming gradually 
thinner and flatter. Associated with this process, and proceeding with 
it step by step, is a condition of contraction taking place in the con- 
junctiva, a condition which steadily increases until even the folds that 
in the normal eye are present in the fornix are smoothed out and dis- 
appear (Fig. 24 B^ at/i). The conjunctiva has grown pale, and a deli- 
cate bluish-white coating is witness to the cicatricial character of its 
superficial layers. 

Pannus, provided that further changes, such as will be described 
later, have not occurred in it, is capable of complete retrogression, so 
that the cornea can reacquire its normal transparency. Ulcers heal, 
leaving behind them cloudy spots, the influence of which upon vision 
is dependent upon the degree of their opaqueness and also upon their 
situation within the pupillary area of the cornea. 

The morbid changes in the conjunctiva and cornea, which are 
characteristic of trachoma, vary so greatly in their intensity that it will 
be necessary to distinguish the cases into those that are light and those 
that are severe. In the lightest cases the hypertrophy of the conjunctiva 
is small and the cicatricial formation that succeeds it is correspondingly 
insignificant ; so much so, perhaps, that it may scarcely be possible any 
longer to make the diagnosis of trachoma, if some time has elapsed since 
it occurred. When once the cornea has become implicated, 'the case 
must always be characterized as severe. It must be remarked how- 
ever : (1) That the symptoms of irritation do not always by any means 
bear a fixed proportion in the objective changes ; cases with very great 
hypertrophy of the conjunctiva and thick pannus often running their 
course without inflammatory accidents and vice versa. (2) That 
similarly no fixed relation exists between the changes in the conjunc- 
tiva of the lids and those of the cornea. We see cases with very pro- 
nounced proliferation of the palpebral conjunctiva without pannus, 
and, on the other hand, cases with pannus and ulcers associated with 
a trifling affection of the conjunctiva. (3) In one and the same case 
the course is often very variable, in that sometimes intermissions or 
even spontaneous partial recoveries, sometimes relapses and exacerba- 
tions, occur. The latter are surely to be expected if, in a case that has 
been improved by treatment, treatment is too soon discontinued ; but 
it is noticed that they also occur without any known cause under ap- 
propriate treatment properly carried out. Thus, a suddenly occurring 
supplemental attack of pannus can in a short time annihilate the results 
of months of treatment. 

It is not only, however, with regard to the intensity of the morbid 
changes, but also with regard to the stviftness with which they take 
place that such great variety prevails, and the same is true of the as- 



DISEASES OP THE CONJUNCTIVA. 



69 



sociated symptoms of irritation, which are usually the more consider- 
able the more rapid the progress of the disease. In the majority of 
cases the disease sets in with moderate symptoms of irritation photo- 
phobia, lachrymation, pain— which augment with the increase in the 
objective changes. Not infrequently, however, trachoma develops so 
insidiously that for a long time those whom it has attacked are not 
aware of it. Such persons sometimes do not have their attention 
called to their disease until the pannus as it covers the cornea begins 
to disturb their sight. These cases belong as a rule to the granular 
form of trachoma. When the people living in barracks, schools, etc., 
that are infected with trachoma undergo medical examination, there is 
always found a number of inmates who do not complain of any troubles 
whatever and who regard themselves as perfectly healthy, while exam- 
ination shows in the folds of transition a very considerable develop- 
ment of trachoma granules. In contrast with cases running this in- 
sidious course are the cases of what is called amte trachoma. In these 
the disease begins with very violent inflammatory accessories; the 
03dema of the lids, the great swelling of the conjunctiva, the profuse 
purulent secretion would almost lead us to imagine the case to be an 
acute blennorrhcea. The correct diagnosis can be made as a rule by 
our finding the conjunctiva studded with numerous trachoma granules. 
But if these are absent during the first days of illness, or if, because of 
the great swelling of the conjunctiva, they are not apparent, the subse- 
quent course of the disease may be the only thing that can clear up the 
nature of the latter ; which it does, since the hypertrophy of the con- 
junctiva, that is characteristic of trachoma, soon develops. Such acute 
cases occur chiefly during the prevalence of an epidemic of trachoma ; 
they are dangerous to sight not so much on account of pannus as of 
corneal ulcers, that make their appearance during the acute stage. 

14. Stage of Sequelae of Trachoma. — It is only the lightest cases, or 
those that come under treatment early, that are completely cured. In 
other cases there are left sequelae, which are accompanied by a per- 
manent impairment of the eye. These affect either the lids and con- 
junctiva or the cornea. They are as follows : 

1. Distortion of the lids with faulty disposition of the cilia. The 
distortion is produced by the cicatricial contraction of the conjunctiva 
and the tarsus, as a result of which the tarsus bends in such a way as 
to be convex anteriorly. This distortion is recognizable even from an 
inspection of the lids while in situ, from the fact that they bulge more 
than usual. It appears still more clearly on everting the lids, especially 
in the upper lid, in which the distortion is always more pronounced. 
We find the conjunctival surface of this lid traversed by cicatrices, 
among which one that is particularly striking is a cicatricial band 
which runs in the form of a narrow white line two or three millimetres 
above the free edge of the lid and parallel with it. Along this line 



10 DISEASES OF THE EYE. 

there is a fnrrowlike depression produced by the drawing in of the 
conjunctiva and the tarsus. On everting the lids we feel that cor- 
responding to this spot there is an angular bend of the tarsus (^i, Fig. 
24 B), which lies, therefore, in the neighborhood of the free border of 
the lid. From this bending of the tarsus the whole lid acquires a boat- 
like or bovvllike shape. 

The cause of the distortion of the tarsus lies partly in the cicatricial 
contraction of the conjunctiva ; for, as the conjunctiva grows shorter 
upon the posterior surface of the tarsus, it tends to bulge the latter 
forward. But the distortion is mainly produced by changes in the 
tarsus itself. The latter is as much the seat of inflammatory infiltra- 
tion in severe cases of trachoma as is the conjunctiva itself. It is hence 
increased in size and, when we evert the lid, we feel that it is thicker, 
wider, and at the same time less pliable, so that sometimes the eversion 
of the lids is rendered considerably more difficult. From such a state 
of things the experienced observer would infer that he has to fear a 
subsequent distortion of the tarsus with its consequences. The infil- 
tration and thickening of the tarsus are greatest near its lower margin, 
along the line at which the blood-vessels passing to the conjunctiva 
from in front perforate the tarsus (see page 39 and Fig. 21, rp). 
There is no doubt but that it is chiefly along these vessels that the in- 
flammatory infiltration makes its way from the conjunctiva to the tar- 
sus. Hence, cicatricial contraction, which succeeds the infiltration and 
which makes the whole tarsus thinner and narrower, is greatest at this 
spot and produces there an angular bending of the tarsus, correspond- 
ing to which is the cicatricial line that is seen running horizontally 
upon the conjunctiva tarsi, and the position of which accordingly agrees 
in general with that of the sulcus subtarsalis present in the normal lid. 

The immediate consequence of the distortion of the lid is an altera- 
tion in the position of its free border and of the cilia springing from it. 
In the upper lid the free border no longer looks straight downward, but 
downward and backward (inward). The internal margin of the lid, 
which in the healthy state is sharp, becomes rounded off (" worn down ") 
and is no longer to be recognized with distinctness (Fig. 24 B, rj), 
this being due partly to the way in which it is drawn by the contract- 
ing conjunctiva, partly to the pressure of the eyeball upon it. By the 
turning inward of the free border of the lid the direction of the cilia 
(ci) is changed, so that they now no longer look forward, but look 
downward and backward, and touch the surface of the cornea (trichi- 
asis). Another factor besides the distortion of the tarsus that con- 
tributes to this false position of the cilia, is the tension which the con- 
tracting conjunctiva exerts. This tends to draw the skin, and with it 
the cilia, over the free border of the lid and up upon the posterior 
surface. 

If the distortion of the lid progresses, the entire border of the lid 



DISEASES OP THE CONJUNCTIVA. 



n 



turns backward and eniropion is produced. In trichiasis and entropion 
alike tliere is a permanent condition of irritation, whicli is excited and 
maintained in tlie eye by the constant contact of the cilia with the 
cornea ; if this condition lasts any length of time, diseases of the cornea 
make their appearance as a consequence of the mechanical injury pro- 
duced by the cilia (see §§ 34 and 44). 

The opposite kind of anomaly of position of the lid— that is, its 
turning outward, or ectropion — also occurs as a result of trachoma. The 
cause of this is that the conjunctiva, when it is thickened and has un- 
dergone great proliferation, crowds the lid away from the eyeball ; the 
contraction of the muscular fibers of the orbicularis then sufBces to 
complete the eversion of the lid. This kind of ectropion is usually 
found only in the lower lid (see § 111). 

2. Symblepharon Posteriiis. — When the cicatricial contraction of 
the conjunctiva reaches a high degree, the folds of the region of tran- 
sition flatten out completely ; the conjunctiva passes directly from the 
lid to the eyeball (/„ Fig. 24 B). If the lower lid is drawn down with 
the finger, the conjunctiva stretches tightly in the form of a vertical 
fold between the lid and the eyeball, and if the lid is drawn down still 
farther, the eyeball, being fastened tightly to it by the conjunctiva, 
must follow. This condition is characterized as symblepharon pos- 
terius (see § 23). In particularly severe cases the lower half of the 
conjunctival sac is reduced to a shallow groove between the lid and the 
eyeball. 

3. Xerosis Conjtinctivm. — This condition develops when the con- 
junctiva, owing to excessive atrophy, loses its secretory functions. A 
steady diminution in the lachrymal secretions, which occurs at the same 
time, contributes to the production of the xerosis. Xerosis manifests 
itself by the following signs : The secretion, formerly copious, now be- 
comes steadily scantier and assumes a tough, sticky, viscid character. 
In conjunction with this, a feeling of dryness develops in the eye. 
Subsequently there appear on the conjunctiva tarsi several dry-lookiug 
places, to which the lachrymal fluid can not adhere any more than if 
they were smeared with grease. This condition tends to spread, until 
finally the conjunctiva may be aifected by it throughout its whole 
extent. The cornea, which as a rule has become partly cicatricial from 
previous pannus and ulcers, likewise suffers from the deficient moisten- 
ing ; its epithelium becomes thicker, epidermoid, dry upon the surface, 
and hence opaque. Thus is produced that melancholy condition which 
is called xerophthalmus and which forms the worst termination of 
trachoma; the eye is rendered incurably blind, is disfiguring to its 
possessor, and in addition keeps torturing him with a constant, very 
tormenting sense of dryness (see § 24, Xerosis Conjunctiva). 

4. Corneal Opacities.— These are after-effects, both of ulcers of the 
cornea and of pannus. A recent pannus, it is true, can disappear com- 



Y2 DISEASES OF THE EYE. 

pletely by a process of resorption, so that the cornea reacquires its nor- 
mal transparency. But often further changes take place in the pannus, 
which render its complete disappearance impossible. Among them is 
to be reckoned in the first place (a) the transformation into connective 
tissue, which the pannus undergoes if it lasts for a long time. In this 
the same change takes place in the pannus as in tjie trachomatous 
conjunctiva, a portion of the round cells of which the pannus is com- 
posed growing into spindle-cells and finally into connective-tissue 
fibers. As a consequence of this the pannus becomes thinner, its sur- 
face grows smooth, the vessels with a few exceptions disappear, and at 
length the pannus is transformed into a thin membrane of connective 
tissue which covers the surface of the cornea and hardly admits of fur- 
ther resorption. In cases in which the pannus is quite thick and 
succulent and covers the whole cornea, {b) ectasia of the cornea some- 
times results. That is, as the tissue of the pannus, which is soft and 
abounding in cells, penetrates more deeply into the cornea, the tissue of 
the latter softens and gives way before the intra-ocular pressure (kera- 
tectasia e panno). Such a cornea never becomes perfectly clear again. 
The same thing is true, finally, of those cases in which (c) pannus is 
complicated with ulcers ; the regions which are occupied by the latter 
likewise have permanent opacities left upon them. 

Trachoma, then, is a disease which is distinguished by its duration, 
extending over years, and which in many cases renders those who 
are attacked by it half or wholly blind. If we add to this the fact 
that because of its infectious nature it is exceedingly apt to spread, we 
shall understand hovF, for those regions in which it is endemic, it is a 
veritable scourge. 

15. Etiology. — Trachoma originates exclusively in infection pro- 
ceeding from another eye affected with trachoma. Infection takes 
place by transfer of the secretion ; contagion by means of the atmos- 
phere, the existence of which was formerly accepted, seems not to 
occur. In all probability the secretion owes its infectious character to 
a micro-organism, as to whose nature, however, investigations so far 
have led to no concordant results. Since it is the secretion alone that 
transmits the infection, the danger of infection, which any given case 
carries with it, is in direct proportion to the amount of the secretion ; 
the more profuse the latter, the greater being the danger to those in the 
immediate neighborhood of the patient. The transfer of the secretion 
from one eye to another generally takes place indirectly through the 
medium of the finger or chiefly through the medium of certain articles 
of the toilet, like sponges, towels, handkerchiefs, etc., which are 
brought into contact with the eyes. A special opportunity for this to 
occur is afforded when a pretty large number of people have their 
sleeping apartments in common, and so make common use, too, of the 
articles above mentioned. Hence, trachoma spreads most extensively 



DISEASES OP THE CONJUNCTIVA. ^3 

in barracks, penal establishments, poorhouses, orphan asylums, board- 
ing schools, and indeed schools of all kinds, etc. Moreover, outside of 
such institutions the same factor asserts itself, since trachoma prefer- 
ably attacks poor people who live crowded close together and bestow 
little care upon cleanliness. Moreover, the fact that in many coun- 
tries the Jews are special sufferers from trachoma is to be attributed to 
the same cause. Trachoma, finally, varies in its geographical distribu- 
tion. It is most frequent in Arabia and in Egypt, which is regarded as 
its proper home (ophthalmia JEgyptiaca, Egyptian ophthalmia). In 
Europe it is much more extensively distributed in the east than in the 
west. Elevated lands (Switzerland, Tyrol) are almost entirely free 
from it, while it is very frequently found in the low lands (Belgium, 
Holland, Hungary, and the whole region of the lower Danube). 

Therapy. — The treatment of the trachomatous conjunctiva has a 
twofold object in view : on the one hand it seeks to do away with the 
inflammatory complications and the increase of secretion, which is asso- 
ciated with them; on the other hand, to further the disappearance of 
the conjunctival hypertrophy. In this way it is most likely that the 
process of shrinking in the conjunctiva will be restricted as much as 
possible, so as to avert the evil consequences resulting from its cicatri- 
cial contraction. We attain both objects by the proper employment of 
caustics, of which two are almost exclusively in use; nitrate of silver in 
two-per-cent solution and sulphate of copper in the form of a stick. 
The silver has the feebler action, and is therefore borne better ; cop- 
per, being applied in substance, has a correspondingly stronger cauter- 
ant action, but also causes more irritation. These remedies are, as a 
rule, applied once a day, it being only in severe cases that they are used 
twice a day. The indications for the two remedies are as follows : Ni- 
trate of silver is employed in all recent cases with violent inflammatory 
symptoms and gi-eat secretion. It can also be used when there are 
ulcers upon the cornea that are still in the progressive stage, if we take 
care that none of the solution comes into contact with the cornea 
itself. Copper sulphate is suitable for those cases in which the inflam- 
matory symptoms are small, and its chief use is in removing the hyper- 
trophy of the conjunctiva. For this purpose it acts much more ener- 
getically than the silver solution, and should therefore be used in 
preference to it in all those cases in which its application is allowable 
at all. Great inflammatory irritation, but most of all the presence of 
ulcers of the cornea in a state of active progress, contraindicate the use 
of the bliiestone. 

From these indications it follows that, as a rule, we treat a recent 
case with the silver solution until the inflammatory symptoms have disap- 
peared and the secretion has diminished. As soon as this has occurred 
—and several weeks are generally sufficient for the purpose— we replace 
the silver solution by bluestone. At any rate, we must avoid using 



74: DISEASES OF THE EYE. 

the silver solution for too long a time on account of the argyrosis 
which may develop as a result of it. The copper is now to be used, 
the application of it being made stronger or weaker according to the 
degree of hypertrophy, and is to be kept up for months and even 
years, until every trace of hypertrophy has vanished and the conjunc- 
tiva has become free from congestion and smooth throughout. At first 
the application is made every day ; but when only slight remains of the 
hypertrophy exist, it is sufficient to make the application every other 
day, and subsequently every third day ; and at this stage, the milder act- 
ing alum pencil (a sliver of alum whittled down to a fine edge) may be 
substituted for the bluestone. Moreover, the application should be 
made less and less energetically all the time, until, finally, when the 
cure of the trachoma is complete, the application is entirely suspended. 
In these later stages of the disease we can instruct the patient how to 
evert the lid himself and touch it with the bluestone, so that he need 
not come so often to the physician. Or, we can prescribe for him an 
ointment of copper sulphate (one half to one per cent), which he himself 
can rub into the conjunctival sac. When there is gi'eat cicatricial con- 
traction of the conjunctiva the bluestone is not applicable at all, and 
must be replaced by ointments. A one- or two-per-cent ointment of 
white or yellow mercurial precipitate (the latter acts more energetically) 
may be rubbed into the conjunctival sac. In relapses with great in- 
flammatory irritation, such as often occur in the course of the treat- 
ment, the copper is always to be replaced for a short time by the silver 
solution. If, however, the symptoms of irritation are very violent, the 
silver solution itself can not always be borne, and must then be re- 
placed for some time by milder remedies, such as instillations or com- 
presses made with weak solutions of corrosive sublimate or boric acid. 

The ojjerative treatment of trachoma, which is now a good deal 
practiced, is indicated in cases in which very numerous granulations 
are present in the retrotarsal folds. Excision of the retrotarsal folds, 
which would be the most radical method, is to be rejected because it 
always causes great contraction of the conjunctiva. Much to be pre- 
ferred are those methods that remove the trachoma granules by ex- 
pression without destroying the conjunctiva. This may be done either 
by puncturing the granulations individually with a sharp knife and then 
squeezing them out (Sattler), or by drawing the retrotarsal folds out 
between the blades of Knapp's roller forceps. In the latter instrument 
each blade carries a fluted roller, and when the conjunctiva is drawn in 
between the two rollers, which fit closely into each other, the trachoma 
granules are squeezed out. 

Neither by these nor by any similar methods is an immediate or a 
radical cure of trachoma effected, since along with the larger granulations 
small ones in process of development are always present, which can not 
be removed, and which grow bigger afterward. Hence it is necessary 



DISEASES OP THE CONJUNCTIVA. 75 

after the reaction produced by the operation has subsided to apply 
caustics in the usual way. But it must be conceded that in suitable 
cases the duration of treatment is considerably shortened by resort to 
these operative procedures. 

Keining's method of daily repeated friction of the conjunctiva with 
a l-to-2,000 sublimate solution is also efficient mainly owing to its 
mechanical effect — i. e., to its causing expression of the granules. 

The treatment of trachoma must be kept up until the hypertrophy 
of the conjunctiva is completely done away -with, as otherwise relapses 
are to be looked for sooner or later. The chief difficulty in the treat- 
ment lies in its great length, it often requiring many months for a com- 
plete cure. Those patients who have not the endurance or the means 
necessary for such a course, give up treatment as soon as their subjective 
troubles have disappeared, without, however, being completely cured. 
Then we commonly see them returning after some time with a relapse, 
which is often more severe than the disease for which we originally 
treated them. This lack of completeness in tlie treatment is the reason 
why the disease with many men drags on through their whole life. 

The treatment of complications affectitig the cornea is conducted on 
the principle that the affections of the cornea, caused by a conjunctival 
trouble, are best cured by the treatment of the conjunctival trouble 
itself. Hence, ulcers of the cornea when occurring in connection with 
trachoma are not combated directly, but have their cure brought about 
by means of applications made to the conjunctiva. The only limita- 
tion to this is that, where there are corneal ulcers in active progress, the 
silver solution is demanded and the bluestone, on the other hand, is 
contraindicated, and further, that contact of the caustic with the 
cornea should be avoided as far as possible. For the iiitis, which is 
not rarely associated with ulcers of the cornea, atropine in one-per-cent 
solution is instilled. In other respects, ulcers of the cornea are to be 
treated according to the rules which are in general applicable to them 
(see § 34). It must only be noted that bandaging, which is gener- 
ally indicated in the case of ulcers of the cornea, should be avoided as 
far as possible when trachoma is present, because by the closure of the 
eye the secretion is retained in the conjunctival sac, and thus both the 
conjunctival and the corneal troubles are aggravated. 

Panmts, in recent cases, disappears of itself, simply from applica- 
tions being made to the conjunctiva. If the pannus is unusually dense, 
it is allowable to make careful applications of the caustic to the pannus 
itself. Since pannus is often associated with slight iritis, atropine 
should be instilled from time to time, in order to keep the pupil dilated 
and prevent the formation of posterior synechia;. Very old pannus, 
which already is partly made up of connective tissue and has lost all but 
a few of its vessels, requires special treatment. Experience has shown 
that further resorption can be obtained in such a pannus by exciting a 



76 DISEASES OF THE EYE. 

violent inflammation in it, and so producing an increased succulence 
and a greater rascularity. For this purpose we make use of the je- 
quirity treatment (De Wecker). We here employ a three- to five-per- 
cent infusion of jequirity, which is prepared by steeping the ground 
jequirity beans for twenty-four hours in cold water. With this infusion, 
which is to be prepared fresh every day, the conjunctiva of the everted 
lids is painted very thoroughly two or three times a day. The inflam- 
mation that is thus produced reaches the desired height on the second 
or third day, when the lids are reddened and are swollen with oede- 
ma, the conjunctiva is strongly injected and covered with a croupous 
membrane, and slight chemosis is often present. This inflammation 
we designate as jequirity ophthalmia. As soon as it has attained the 
height just described, the further application of the remedy is discon- 
tinued, as otherwise we should make the inflammation increase to the 
point where it would cause a necrotic disintegration of the conjunc- 
tiva and cornea. We now allow the inflammation to run its course, 
simply keeping the eye clean ; when the inflammation has completely 
subsided, the cornea is found to have gained in transparency as com- 
pared with its former state, and sometimes to a very considerable ex- 
tent. This very energetic treatment is adapted only to those old cases 
of trachoma in which the more pronounced symptoms of inflammation 
are wanting, the conjunctiva is in great part cicatricial, and the cornea 
is entirely covered by old pannus. 

Of the sequelcB of trachoma, trichiasis and entropion demand opera- 
tive treatment (see the section on Operations, §§ 167 and' 170). The 
symblepharon posterius, which is produced by the shrinking of the 
conjunctiva, is amenable to no treatment. Xerosis of the conjunctiva 
is also incurable, so that treatment must be limited to the amelioration 
of the patient's sufferings. To diminish the sense of dryness, frequent 
instillations of milk, glycerin, or mucilaginous substances (e. g., the 
mucilago seminum cydoniorum) may be made. For bad cases Rudin, 
in order to preserve the eyeball from desiccation, has advised refresh- 
ing the edges of the lids and stitching them together, so as to unite 
them throughout except for a small space in their middle. 

In addition to the foregoing measures for the treatment of tracho- 
ma, it is self-evident that care must be taken to keep the eye clean, 
for which purpose we may prescribe weak antiseptic solutions. The 
patient should have a nourishing diet ; he ought not to be kept in his 
room, but, on the contrary, should be made to go out as much as pos- 
sible in the open air and take exercise, and if necessary may be directed 
to engage in some light out-of-door work. 

With a disease of this infectious character, its dissemination should 
be checked by suitable prophylaxis. The physician must set a good 
example, and must cleanse his hands very carefully after touching a tra- 
chomatous eye. He must call the attention of the patient affected with 



DISEASES OP THE CONJUNCTIVA. YY 

trachoma to the infectious nature of his disease. He must teach him 
how to protect from infection the other eye, which may be still healthy, 
and how to avoid spreading the disease among those in his immediate 
neighborhood, his family, his fellow-workmen, etc. Per securing the 
latter object, the prime requisite is that the patient should have his 
own washing materi.als, linen, bed, etc., and should keep them for his 
own individual use. 

The prevention of epidemics of trachoma in public establishments, 
such as barracks and institutions and schools of every sort, constitutes 
an important duty of the officials in charge of such places. These offi- 
cials should take care that the members of their community have separate 
washing materials, linen, etc., for their use. They should be kept ap- 
prised of the presence of any trachomatous patients by means of fre- 
quent medical inspection, and, as soon as such a patient is found, he 
should be immediately removed from the community; for, where no 
trachomatous patient is found, no extension of the disease is possible. 

It was at the commencement of our own century that trachoma began to 
attract the attention of physicians to any great degree. It was then that the 
disease first showed itself as an epidemic among the European armies (ophthal- 
mia militaris). People were of the opinion that it had been introduced into 
Europe from Egypt (hence ophthalmia ^gyptiaca) by Napoleon I. For when 
the latter, in July, 1798, landed in Egypt with an army of thirty-two thousand 
men, most of the soldiers were very soon attacked by a violent ophthalmia, 
and these were supposed to have brought with them upon their return to Europe 
the disease which was formerly confined to Egypt. Subsequent historical re- 
searches, however, have shown that the disease had already been endemic in 
Europe since antiquity. Celsus mentions the disease, and gives a good de- 
scription of the roughness of the lids and the purulent discharge that it occa- 
sions. For treatment the ancients employed scarification of the conjunctiva, 
which is still to-day made use of by some, and which was accomplished both 
by means of various instruments and also by friction with fig leaves. 

From time immemorial, then, trachoma has existed in Europe as an endemic 
disease. But when by reason of the Napoleonic wars the armies came so re- 
peatedly in contact with each other and with the civil population, the disease 
became more widely disseminated and occurred in epidemics. In some coun- 
tries it became frightfully prevalent. In the English army, during the year 
1818, there were more than 5,000 on the invalid list, who had been rendered 
blind as a consequence of trachoma. In the Prussian army, from 1813 to 1817, 
30,000 to 30,000 men were attacked with it; in the Russian army, from 1816 to 
1839, 76,811 men were subjects of the disease. In Belgium, in 1840, one out 
of every five soldiers was affected with trachoma. The French army, which 
was supposed to form the starting-point of the disease, was just the one that, 
relatively speaking, was least attacked. The armies disseminated trachoma 
among the civil population through the discharge of soldiers affected with eye 
diseases, through the quartering of troops, etc. When they had so many 
trachomatous soldiers in the Belgian army that they did not know what to do, 
the Government applied to Jilngken, who was at that time a celebrated oph- 
thalmologist in Berlin. He recommended them to dismiss the trachomatous 



78 DISEASES OF THE EYE. 

soldiers to their homes. By means of this fatal measure trachoma soon became 
diffused in Belgium to an extent which has been observed in no other European 
state. 

Among the eiml population trachoma finds a favorable soil for its dissemina- 
tion in places where many men dwell together, hence among the poorer classes, 
but particularly in large public asylums. If trachoma has made its way into 
such an establishment, and no measures are taken against its spreading, soon 
a great number or even all the inmates will be attacked by it. In a pauper 
school at Holborn, the whole five hundred children suffered from trachoma 
(Bader). Hairion, in 1840, found in an orphan asylum at Mecheln sixty-four 
out of sixty-six orphan girls affected with trachoma; in Mons, seventy-one out 
of seventy-four orphan girls were suffering from the disease. In the workhouse 
at Dublin, no less than 134,838 persons were attacked by trachoma from 1849 
to 1854. On board ships, where the crew live so closelj' crowded together, 
trachoma can spread very quickly. Mackenzie tells the story of the epidemic 
which raged upon the French slave ship Rodeur in the year 1819. The disease 
broke out during the voyage, and first among the negroes who, t^ the number 
of 160, were crowded together in the hold. When they took the unfortunate 
people up on deck, because the fresh air seemed to have a favorable influence 
on the ophthalmia, many threw themselves overboard, so that they had to desist 
from doing this. Soon one of the sailors also was attacked, and three days 
later the captain and almost the whole crew were taken, down with the disease, 
so that it was only with the greatest difficulty that the ship could be brought 
to its destination. 

According to the descriptions of that time, trachoma then ran a very acute 
course, and was attended with profuse secretion, circumstances which explain 
the rapidity with which the disease spread. Now that epidemics have ceased, 
this acute form has become rare. At present trachoma exists in many countries 
as an endemic disease, but mostly occurs under that chronic form under which, 
with scarcely any exceptions, we now see it. At the same time, its prevalence 
has diminished. In 1 888 the Prussian army had but ten trachoma patients for 
every 1,000 soldiers. In Austria, in whose eastern provinces trachoma is still 
very prevalent, 8 out of every 1,000 were affected with trachoma annually dur- 
ing the years 1881 to 1890. In the Orient there is a very different state of 
affairs. Thus in Egypt, even at the present time, it is scarcely possible to find 
a native who has a normal conjunctiva, and innumerable people there are blind. 
I'o be sure, the disease which plays such havoc and is known there as Egyptian 
ophthalmia comprises not only trachoma, but also acute blennorrhoea, which 
during the hot season does enormous injury. 

The different forms under which trachoma shows itself nowadays are re- 
garded by some as distinct diseases, and are denoted by different names, so that 
quite a good deal of confusion has gradually arisen in their nomenclature. In 
order to discover the relation existing between these forms, we must study first 
of all the anatomical alterations which characterize them. 

The papillary growths wliich impart to the conjunctiva its velvety or rasp- 
berrylike appearance are caused by an increase in size of the surface of the 
hypertrophic conjunctiva. The latter is thrown into folds, between which cor- 
respondingly deep clefts are formed; then on cross-section the folds appear 
under the form of papillae (Pig. 35, P and P,)- The connective tissue forming 
the papillae is stuffed full of round cells ; the surface of the papillce is covered 



DISEASES OF THE CONJUNCTIVA. 



79 



■with a very much thickened epithelium (e, e), which, of course, is continued on 
into the depressions {t, t) that exist between the papilla. These depressions 
hence have in microscopical cross-section the appearance of a narrow canal 
coated with epithelium, and were accordingly regarded at one time as tubular 
glands; and hence the formation of new glands was alleged to occur in tracho- 
ma. That this in fact does sometimes occur can not be absolutely denied, for, 
even though the depressions between the papillae are not glands, yet tubes 




Fig. 25.— Cross-section through the TEACHOMiTon? Conjunctiva op the Upper Lid. 

Magnified 24 x I. 

Both small papillae, P. P, P, and large ones, P,. P,, are found. The former stand side by side 
like the pickets n( a palisade : the depressions, t, t. t, lying between them and coateii with 
epithelium, look like the tubules of glands. The large papillee contain trachoma granulps, 
T, Ti, which are not sharply limited and do not possess a capsule. The f pithelium of the 
conjunctiva is in many places, e. e, thickened. The mucous coat is in a condition of cellular 
infiltration, o, which is especially marked in the vicinity of the blood-vessels, g, g. 



coated with epithelium grow out from them and extend into the tissue of the 
conjunctiva, and these tubes are then in no respect distinguishable from true 
glands. 

Papillary hypertrophy of the conjunctiva, however, is by no means a char- 
acteristic feature of trachoma, in the sense of being limited to it alone. In a 
less marked degree it is found in connection with every long-continiicd irrita- 
tion of the conjunctiva ; as in chronic catarrh, in conjunctivitis eczematosa that 
has lasted a long time, in ectropion upon the portion of the conjunctiva that 
is exposed to the air, etc. Papillae, that are large but compressed and flat are 
the di-tinguishing mark of vernal catarrh (% 19). Still more intense degrees of 
papillary growth are observed after acute blennorrhoBa whenever the so-called 
chronic blennorrhoea develops from it. For this reason many authors call all 
cases of papillary trachoma chronic blennorrhoea, even though they have not 
been preceded by acute blennorrhoea. Others call the papillary form ophthal- 
mia purulenta chronica, others conjunctivitis granulosa or gra-.ii lations, because 
the papillae of the conjunctiva have a resemblance to the granulations of a 
wound. This resemblance, however, is a purely external one, fince the hyper- 
trophied conjunctiva does not have a raw surface, but is covered with epithe- 
lium; besides, by such a designation, a confusion would necessarily be produced 
with the granular form of trachoma. 

The granular form is characterized by the presence of trachomatous granu- 
lations. These, in microscopic cross-section, appear as a rounded aggregation 
of lymph corpuscles, forming, as it were, a little lymphatic gland or a lymphatic 
follicle, analogous to those which compose Peyer's patches. The trachomatous 



80 DISEASES OF THE EYE. 

granulation either passes without any sharp line of demarcation into the sur- 
rounding tissue, which is also very rich in cells (Fig. 35, T and T^), or it has, 
especially in the case of the older granulations, a sort of incomplete capsule of 
connective tissue (Fig. 36, h). 

The subsequent fate of the trachoma granulations varies: some are gradu- 
ally transformed into tough connective tissue ; others undergo softening in 




9 

Fro. 36.— Trachomatous Granulation prom the Fou) of Transition. Magnified 24 x 1. 

The trachomatous granulation, T, pushes up the conjunctiva in the form of an elevation, and is 
inclosed by a layer of thickened connective tissue, the capsule, k. The conjunctiva is in- 
filtrated with cells, both in its upper layers, a, and along the vessels, g ; the epithelium, e, 
shows, above the place marked a, bright spots which correspond to the goblet cells ; at d It 
lines one of Henle's glands. 

their interior, and then by the breaking down of their investing epithelium are 
evacuated externally. In this case the loss of substance that remains is closed 
in by cicatrization (Raehlmann). 

The granular form is called trachoma verum, trachoma Arlti, and trachoma 
folliculare (Horner). Many, in view of the trachomatous granulations (gran- 
ules) present, give this form the name of granulations, while, as has been said 
above, others, on the contrary, use just this expression for the papillary form ; 
hence the confusion that exists. 

The mixed form (trachoma mixtum, according to Stellwag), which clinical 
observation has already shown to be the most frequent, is proved by micro- 
scopical examination to be almost the only one that occurs. That is, even in 
those cases in which papillae alone appear to the naked eye to be present, 
trachomatous granulations are found in cross-sections examined under the micro- 
scope, either lying within the papillae themselves or imbedded in the deeper 
portions of the mucous membrane. In the former case the papillae have a par- 
ticularly broad or even knob-shaped appearance (Fig. 25, Pi). In the second 
case the trachomatous granulations are concealed by the papillary bodies, be- 
neath which they lie ; then we often see them coming into view afterward, when 
the papillary growths have disappeared, as the result of a prolonged course of 
treatment. 

The gelatinous trachoma of Stellwag represents a later stage of mixed tracho- 
ma, in which a more uniform lymphoid infiltration exists in conjunction with 
superficial cicatricial changes. We have in that case a conjunctiva which is 
thickened, smooth on the surface, yellowish, and of gelatinous translucency. 

The transformation of the conjunctiva into cicatricial tissue proceeds as fol- 
lows : A part of the numerous cells which are contained in the conjunctiva, and 
which are either uniformly scattered through it or occur in circumscribed ac- 



DISEASES OP THE CONJUNCTIVA. 81 

cumulations (trachomatous granulations), disappears by resorption ; another 
part owing to rupture of the granulations empties externally ; and still another 
part gradually grows into spindle-shaped cells, and finally into connective- 
tissue fibers. This new-formed connective tissue shrinks, and to such a great 
extent that the conjunctiva contracts and becomes thinner and of tendinous 
character. We have here a process similar to that which occurs in cirrhosis of 
the liver — i. e., the shrinking of a new connective tissue which has developed 
out of an inflammatory infiltration. It would be a mistake to suppose that in 
the trachomatous conjunctiva there are raw spots which become covered with a 
cicatrix — a mistake into which we might be more apt to fall because of the term 
granulations. What we call granulations in trachoma have nothing at all in 
common with the granulations of wounds, except their external appearance. 

Pannus proves, upon histological examination, to be a layer of new-formed 
tissue, which, starting from the limbus, spreads over the cornea (Fig. 27, P). 
It is a soft tissue, extremely rich in cells, which greatly resembles the infiltrated 
trachomatous conjunctiva. This tissue abounds in vessels, and occurs in alter- 
nately thicker and thinner layers, for which reason the pannus looks uneven 
and nodulated. Pannus, when it begins, insinuates itself between Bowman's 
membrane (Pig. 37, B) and the epithelium (Fig. 27, U), the latter being thus 
lifted off from Bowman's membrane and made to cover the pannus. The pa- 
renchyma proper of the cornea is protected by the still intact Bowman's mem- 
brane and sufl:ers no essential change. Hence it is possible for the cornea to 
regain completely its normal structure and transparency after the resorption of 




Fig. 27.— Cross-section through the Margin of a Cornea affected with Pannds. 
Magnified 1S5 x 1. 

Beneath the epithelium, E. E, is the limbus, i, greatly thickened by cellular ii^ltration; from 
it the pannus, P. in which are perceived the cross-sections ot several vesse s, extends be- 
tween the epithelium and Bowman's membrane, B, over the cornea, c. .b, sclera. 

the pannus, since then the epithelium is once more directly applied to Bowman's 
membrane. But this is possible in recent and slight cases only of pannus; later. 
Bowman's membrane gets to be destroyed in places, and the pannus then pene- 
trates into the corneal tissue proper, the superficial layers of which consequently 
are also destroyed in spots. Then the complete restoration of the transparency 
of the cornea has become impossible. 

For some forms and stages of pannus special names are in use. A recent 
pannus, which has not yet become thick, is called pannus tenuis, and, if it is 
very vascular, pannus vasculosus. If the pannus has acquired a considerable 
thickness, it is then known as pannus crassus or pannus carnosus. Sometimes 
the pannus is so big that one might imagine that he was looking at exuberant 
6 



82 DISEASES OF THE BYE. 

granulations ("proud flesh") upon the affected region of the cornea. This 
is pannus sarcomatosus. This adjective is also applied to the proliferating 
conjunctiva, as, for example, in the expression ectropion sarcomatosum. It 
would be best to discard these antiquated expressions altogether, and especially 
the designation sarcomatosus, which can give rise to confusion with neoplasms 
— sarcomata. An old pannus, composed of connective tissue and poor in ves- 
sels, is a pannus siccus. 

A rare metamorphosis of pannus has been observed in whicli tliere develops 
from it a dense white or yellowish tissue containing very few vessels. This 
tissue resembles a dense scar, e. g., such as occurs after deep ulcers of the 
cornea, but, unlike the latter, replaces only the superficial layers of the cornea ; 
extending, for example, from the upper border to the center of the cornea, if 
the pannus itself had covered the upper half of the latter. Another change in 
old pannus consists in the development of small, intensely white spots, ^-ihich 
frequently form a group in the pupillary region of the cornea. The appearance 
of the spots, which lie close to the delicate blood-vessels of the pannus, re- 
minds one of lead incrustation. The spots are superficial in seat, and may be 
removed by scraping (§ 45). 

'For pseudopterygium, see § 32. 

What are the causes of pannus in trachoma ? Some see in pannus a direct 
transfer of the inflammatory process from the conjunctiva of the region of transi- 
tion to the cornea. Against the occurrence of any such transfer per continuitatem, 
it has been urged, and with justice, thpt that portion of the conjunctiva which is 
interposed between the fold of transition and the rim of the cornea, namely, the 
conjunctiva bulbi, takes little or no part in the trachomatous process. Another 
explanation starts from the fact that pannus in trachoma as a rule begins in the 
upper half of the cornea, and under ordinary circumstances has covered this 
portion entirely, before the lower half has been attacked at all. This would 
indicate that the upper lid, by reason of the roughness of its conjunctival sur- 
face, causes mechanically an irritation of the upper half of the cornea, and thus 
gives rise to inflammation in it. It is not to be doubted that this factor does 
come into play in the production of pannus, but it can not be the only nor even 
the most important cause of pannus ; for we often find the greatest roughness of 
the palpebral conjunctiva without pannus, and conversely find pannus in cases 
in which the palpebral conjunctiva is almost perfectly smooth. At the present 
time we can merely say that anatomically pannus is analogous to trachoma of 
the palpebral conjunctiva; that it is a trachomatous affection of that part of 
the conjunctiva which covers the cornea— i. e., of the conjunctival layer of the 
cornea. That this part of the conjunctiva becomes diseased in trachoma as 
readily as the conjunctiva of the lids or of the fold of transition, should not 
excite our wonder; on the contrary, it is more difficult to understand why the 
remainder of the conjunctiva, the conjunctiva scleras, does not take a more 
active part in the trachomatous process. Perhaps the following explanation is 
the correct one. Fig. 27 shows that the infiltration of small cells is particularly 
marked in the limbus of the cornea {L), and gradually diminishes as it extends 
from the latter over the cornea itself. So also, where we make a macroscopical 
inspection, we find the limbus, at the spot where a pannus is on the point of 
developing, intensely reddened and so greatly swollen that sometimes it forms 
quite a thick outgrowth. Hence the impetus to the formation of a pannus 
seems to be given by the trachomatous affection of the limbus. Now, then, we 



DISEASES OP THE CONJUNCTIVA. 83 

must propound the following questions: 1. Why is it that the limbus in par- 
ticular is affected so intensely in trachoma ? and, 2. Why does the inflamma- 
tion pass from the limbus to the cornea and not in the opposite direction — i. e., 
to the scleral conjunctiva ? The first question must iind its explanation in the 
fact that the limbus is by far the most vascular portion of the bulbar conjunc- 
tiva, and hence the part that is the most apt to be inflamed. That the inflam- 
mation spreads from the limbus in a centripetal direction— that is, upon the 
cornea, and not in a centrifugal direction upon the conjunctiva sclera;, agrees 
vfith what we have been able to observe in other affections of the limbus and of 
the adjacent portions of the cornea. We are acquainted with many diseases in 
which inflammatory infiltrations or vessels push their way inward from the 
limbus into the cornea. Probably this depends upon the centripetal direction of 
the circulation of the blood in the scleral conjunctiva. The arterial vessels run 
from the periphery toward the limbus, where they form a dense network of capil- 
lary loops. At this point, where the centripetal stream of blood finds its limits, 
a circulation of lymph begins, which is directed in the same sense and which 
enters the cornea; and it is in the same direction that the inflammatory prod- 
ucts advance, and that the blood-vessels which jut out from the marginal loops 
of the cornea tend to make their way. Finally, it still remains to be explained 
why pannus generally begins at the upper margin of the cornea or why, in 
other words, the limbus is first affected at this point. If an eye is infected 
with trachoma, the conjunctiva is not attacked by the infection in its whole 
extent alike, but the infective matter adheres first to some circumscribed por- 
tion of the conjunctiva — generally to the conjunctiva of the tarsus or of the 
fornix, which is particularly apt to be affected with trachoma. Now, there are 
two ways in which the affection can spread from the portion of conjunctiva 
that is first attacked to other parts, namely, by continuity, in which case it 
extends gradually over the neighboring parts; and, by contiguity, in which 
case through contact with the diseased conjunctiva tarsi there is an infection of 
those portions of the conjunctiva bulbi that lie opposite tlie former, and espe- 
cially of the limbus, which is especially predisposed to infection. Now, it is 
precisely at the upper margin of the cornea that the limbus is in contact with 
the conjunctiva of the upper lid, and that, too, not only at night, but also all 
day, while the eye is open, since normally, even when the eye is open, the upper- 
most part of the cornea is covered by the upper lid. Here, therefore, the con- 
stant contact that exists is most favorable to an infection of the limbus by the 
diseased conjunctiva of the lids. That the rough condition of the latter assists 
in the production of this infection is likely. Such a condition acts partly as 
a mechanical irritant, partly by giving an impetus to infection through the 
production of small multiple lesions of the conjunctival and corneal epi- 
thelium. 

The pfmis which almost always accompanies trachoma and which gives tra- 
chomatous patients their characteristic appearance is in many cases attributable 
to the fact that the lid droops because it is heavy. Ptosis, however, is ob- 
served even when the thickening of the conjunctiva is inconsiderable, or indeed 
not present at all, and sometimes patients come to a physician solely on account 
of the ptosis, without having experienced any other trouble from their trachoma. 
There must therefore be some other cause for the ptosis beside the thickening 
of the conjunctiva. I suspect that the unstriated elevator of the lid (musculus 
palpebraUs superior— see § 105 and Fig. 21, p), whose muscular fibers lie directly 



84 DISEASES OP THE EYE. 

beneath the conjunctiva of the retrotarsal fold, participates in the inflammation 
of the latter, and consequently becomes paralyzed. 

What relation do the separate forms of trachoma bear to each other ? Is 
trachoma papillare (blennorrhoea chronica, etc.) a disease perfectly distinct 
from trachoma granulosum (trachoma verum, etc.), or are both merely different 
forms of the same process ? Anatomy shows that in the enormous majority of 
cases the changes that are characteristic of the two forms (papillary growths and 
trachomatous granulations) are found simultaneously, so that scarcely any un- 
mixed cases of either form are left. This speaks decidedly for the unitary theory 
of the disease. We arrive at the same result if we follow out the etiology of the 
disease. Cases are observed in which one individual affected with one of the two 
forms infects other persons, in some of whom thereupon the same form, in others 
the other form develops. Piringer, moreover, by his inoculations experimentally 
established the fact that the secretion from one and the same case produced the 
first form in one individual, the second form in another; indeed, in one and the 
same person there was once produced by inoculation with the same secretion 
one form in one eye, the other form in the other. We are therefore quite 
justified in regarding the two forms of granular and papillary trachoma as one 
and the same disease. 

It still remains to speak of the position of follicular conjunctimtis with re- 
gard to trachoma. The former is found chiefly in young people, while tracho- 
ma, on the contrary, is very seldom met witli in children. The two diseases 
are very similar, in that lymph follicles occur as characteristic formations in 
both. In follicular catarrh they are smaller, are more sharply limited, and pro- 
ject farther above the surface of the conjunctiva ; in trachoma they are larger, 
destitute of sharp outlines, and less prominent. Follicles proper are often 
oblong-oval (cylindrical) and placed side by side, in a row like a string of 
pearls, while trachomatous granulations are round and more rarely present any 
such arrangement in rows. But these characteristics are sometimes so obscured 
that even experts can not, in many cases, make the diagnosis with certainty, 
and the subsequent course of the disease alone affords the desired information. 
Even in the histological structure no thoroughgoing distinction can be found 
between follicles and trachomatous granulations. A further resemblance be- 
tween follicular catarrh and trachoma consists in the fact that they both chiefly 
occur among bodies of men who are confined in a small space. It is therefore 
easy to understand that these two diseases have repeatedly been confounded with 
each other ; and a number of authors, in fact, explain follicular catarrh as being 
a kind of trachoma distinguished by its mildness and freedom from danger. 
But to such a view the following objection must be raised : It is not yet certain 
whether follicular catarrh occurring among conBned bodies of men is propa- 
gated by infection, like trachoma, or is merely a result of the contamination of 
the air by dust, exhalations, etc. On the other liand, it is quite satisfactorily 
established that, uuder certain circumstances, follicular catarrh can arise with- 
out any infection whatever. This is the case after the prolonged instillation of 
atropine, which is followed in many persons by the development of a typical 
follicular catarrh with very numerous follicles. But trachoma can never arise 
without infection. A further and more important distinction between the two 
diseases is the course. Follicular catarrh is not associated, or is associated to 
only an inconsiderable degree, with papillary hypertrophy of the conjunctiva; 
it never leads to shrinking of the conjunctiva, to pannus, or to any of the other 



DISEASES OP THE CONJUNCTIVA. 85 

sequelse; it is a disease perfectly devoid of danger, one which, even without 
any treatment, finally gets well and leaves no trace behind; so that on this 
account alone the differentiation of the two diseases is not only theoretically, 
but also practically, of great importance. 

The question with regard to the relations of the different forms of blennor- 
rhoea, trachoma, and follicular conjunctivitis to each other will first receive a 
definitive solution through the medium of bacteriology. At present only the 
micrococcus of acute blennorrhoea, the gonococcus, has been satisfactorily de- 
termined. In conjunctival diseases which, like trachoma and follicular catarrh, 
are associated with the formation of granulations several observers (Leber, 
Battler, Koch, Michel, and others) have also proved the existence of micro- 
organisms, some of which pretty closely resemble the gonococcus without being 
identical with it. So far, however, the observations of individual investigators 
are not sufficiently accordant for us to be able to formulate any definite conclu- 
sions. Probably we must regard the formation of granulations composed of 
adenoid tissue not as anything at all specific, but only as a particular form of re- 
action, which the conjunctiva of the eye, like other mucous membranes, exhibits 
toward many different sorts of irritants. Such a formation of granulations occurs 
in its most pronounced form in trachoma and in follicular catarrh. Furthermore, 
in the chronic stage which follows acute blennorrhoea granulations in the retro- 
tarsal folds are frequently found in conjunction with the papillary hypertrophy 
of the conjunctiva, and sometimes in such quantity that a true trachoma is 
thought to be present. Then there are cases of tuberculosis of the conjunctiva 
(see § 19) which begin with an abundant development of granulations, quite 
as in trachoma; of these Rhein has described some examples, and I myself have 
seen several. Again, Goldzieher and Sattler have seen cases in which there was 
an abundant formation of granulations in a conjunctival affection which they 
regarded as syphilitic. 

The former observer also described under the name of lymphoma conjuneti'ca; 
a disease in which gigantic lymph follicles are found in the conjunctiva, to- 
gether with lymphomata in the neck on the same side as the affected eye. 

In regard to the follicular catarrh produced hy atropine, it appears that the 
irritation is a chemical one, and hence the catarrh disappears when the atro- 
pine is replaced by another mydriatic. 

For getting rid of a thick pannus many employ peritomy. This is the opera- 
tion of dividing the conjunctival vessels running to the pannus, either by simply 
making an incision round the cornea through the conjunctiva, or by excising a 
narrow annular strip of the latter. 

In order to make an old pannus transparent, it was formerly the practice to 
deliberately make an inoculation of acute UennorrMa, because it had been 
found by experience that an eye with pannus which is accidentally attacked 
by acute blennorrhcea, instead of losing its cornea by suppuration, has its pannus 
niade actually more transparent. The procedure is, at the present time, re- 
placed by the treatment with jequirity, which accomplishes the same thing 
without exposing the eye of the other side, or the eyes of other persons, to the 
danger of blennorrhoeal infection. 

Jequirity (the seeds of the Abrus praecatorius) has for a long time been in use 
in Brazil, where trachoma is epidemic, as a popular remedy for this disease. 
To De Wecker is mainly due the credit of having subjected this remedy to 
scientific examination and of having introduced it into Europe. The action of 



86 DISEASES OP THE BYE. 

jequirity does not depend upon the presence of micro-organisms in the infusion, 
as was originally believed, but upon an unorganized ferment which is excess- 
ively poisonous (Hippel, Neisser, Salomonsen, Venneman). 

IV. Conjunctivitis Diphtheeica. 

16, Conjunctivitis diphtherica,* like acute blennorrhoea and tra- 
choma, is a purulent inflammation of the conjunctiva which spreads 
by contagion and the secretion of which is infectious. But the con- 
tagium is different from that of the other two diseases, being in this 
case the diphtheria bacillus of Loffler. The inflammation produced by 
this is always violent, and in the severe cases is among the most intense 
of any that are observed in the conjunctiva. The lids are much swollen 
and reddened, hot, and painful to the touch. In particularly severe 
cases the lids are actually of boardlike hardness, so that it is impos- 
sible to evert them, and scarcely possible even to open the palpebral 
fissure. The lymphatic glands in front of the ear or in the neck are 
swollen. The appearance of the conjunctiva is characteristic of the 
property that the diphtheria bacillus possesses of producing a profuse 
exudation, which has a great tendency to coagulate. This coagulation 
either affects the exudate that is poured out upon the surface of the con- 
junctiva, and which consequently clots to form membranes or it takes 
place within the tissue of the conjunctiva. Consequently we may dis- 
tinguish two forms of diphtheria of the conjunctiva. 

(a) The sitperjlcial or croupous form. This is characterized by the 
presence of a grayish-white membrane, which adheres pretty closely to 
the surface of the conjunctiva, but still can usually be removed from it 
with a forceps. When this is done we find the conjunctiva beneath to 
be greatly reddened and swollen and in some places bleeding, but we 
notice no great losses of substance in it. The membrane itself consists 
of a fibrous meshwork of clotted fibrin, in which pus corpuscles and a 
few epithelial cells from the conjunctiva are imbedded. The croupous 
membrane covers the tarsal conjunctiva ; more rarely, the retrotarsal 
fold and even the conjunctiva of the eyeball. In most cases after from 
one to two weeks the membrane gradually disappears. The eye now 
merely presents the condition of an intense simple catarrh, which gets 
well without leaving any permanent changes in the conjunctiva. In 
severe cases the disease is complicated with corneal ulcers, which, how- 
ever, but rarely lead to extensive destruction of the cornea. 

(b) The deep form (diphtheria of the conjunctiva in the narrower 
sense). This runs a much more serious course than does the superficial 
form, as in order for it to occur the exudate must coagulate while still 
within the tissues of the conjunctiva, so that the vessels are compressed 
by it, and the mucous membrane consequently is rendered rigid and 



* Prom Stipdtpa, a membrane. 



DISEASES OF THE CONJUNCTIVA. S7 

bloodless and falls a prey to necrosis. Hence, on everting the lids we 
find beside the marked swelling and redness of the conjunctiva spots in 
which the conjunctiva is somewhat depressed, smooth, and of a grayish- 
yellow color, and often contains a few dirty-red speckled markings 
(ecchymoses). In the severest cases, either a very large portion of the 
conjunctiva, or even its entire surface, acquires this character and is uni- 
formly gray and hard, just as it is after being intensely cauterized, 
e. g., by the action of quicklime. 

The condition just described, which develops rapidly after a short 
period of incubation, is called the first stage of the disease, or stage of 
infiltration. It keeps up for from five to ten days, according to the ex- 
tent of the diphtheritic process upon the conjunctiva. Then the spots 
of diphtheritic infiltration begin gradually to disappear. Where the 
infiltration is not so very dense, resorption of the exudate occurs, but 
in those spots from which the circulation has been altogether cut oif 
by the infiltration and the tissue has consequently mortified the 
necrotic portions slough away. Thus are produced in the conjunctiva 
losses of substance, which soon become covered with granulations such 
as cover a raw surface. Meanwhile the secretion has become more 
abundant and more purulent, for which reason this second stage is 
characterized as the stage of Hennoi-rlima. The third stage is that of 
cicatrization., in which the granulating surfaces, that are produced by 
the sloughing oS of the gangrenous portions of the conjunctiva, grad- 
ually grow smaller and are covered over with a new epithelial lining. 
Since the latter change is effected by the drawing in of the neighbor- 
ing conjunctiva, the conjunctival sac as a whole is contracted ; fre- 
quently, too, in single spots adhesions are produced between the con- 
junctiva of the lid and that of the eyeball (symblepharon). The more 
extended the diphtheritic process the more striking is the subsequent 
cicatricial contraction of the conjunctiva. As a result of it trichiasis, 
cicatricial entropion, or even xerophthalmus may subsequently develop. 

The deep form of diphtheria is more severe than the croupous, not 
only in regard to its effect upon the conjunctiva, but also in other re- 
spects. Hence the cornea is much more frequently and much more 
seriously affected. The greater the extension of the diphtheritic pro- 
cess upon the conjunctiva the more certain is corneal suppuration to 
occur. If the entire area of the conjunctiva is infiltrated and rigid 
the cornea is always irretrievably lost. 

The general condition of the little patients is very much disturbed. 
They have high fever and are greatly prostrated. Weakly children not 
infrequently succumb to the severity of the general disease. The prog- 
nosis, therefore, is very serious, not only as regards the eye, but also 
with respect to life itself. 

Etiology.— That the two forms just described, which differ so much 
in their appearance and course, are, nevertheless, the same disease. 



88 DISEASES OF THE EYE. 

namely diphtheria, is proved from the fact that Lofder's bacilli are found 
in the conjunctival secretion in both. Often, too, the patients present 
other important and undoubted diphtherial affections. Small-sized 
diphtherial patches are frequently found at the edges or angles of the 
lids, the nostrils, or the angles of the mouth ; sometimes there is also a 
fully developed nasal or pharyngea,! diphtheria. 

Diphtheria of the conjunctiva is mainly observed in those countries 
where diphtheria of all sorts is a frequent occurrence,* and occurs es- 
pecially at times when an epidemic of pharyngeal diphtheria is prevail- 
ing. It can often be proved that children affected with diphtheria of 
the conjunctiva had previously been thrown with others, who soon 
afterward developed pharyngeal diphtheria; and such children may 
themselves in their turn spread the disease to others still. The predispo- 
sition to diphtheria diminishes with the age. Consequently, diphtheria 
of the conjunctiva usually attacks children, and most frequently those 
between the second and eighth year of life. Adults are only exception- 
ally attacked, and then by one of the lighter forms. 

Treatment. — In the severe cases of diphtheria of the conjunctiva 
the injection of antitoxin is indicated as soon as the diphtherial charac- 
ter of the disease is made out. In the lighter cases we may content 
ourselves with employing local treatment alone. In the first stage of 
the disease this is chiefly limited to careful cleansing of the eye, for 
which purpose the best thing for us to employ is a weak antiseptic 
liquid (solution of corrosive sublimate, salicylic acid, or potassium per- 
manganate). Cold compresses, which would seem to be indicated by 
the great swelling and redness of the lids, must be applied only when 
the conjunctival circulation is not too seriously embarrassed by the 
diphtherial infiltration. Otherwise, it is better to employ warm com- 
presses which by dilating the blood-vessels increase the circulation. As 
regards the conjunctiva itself Fieuzal has recommended painting it 
with lemon juice ; and painting it with strong sublimate solution 
(1 to 1,000) either directly or after the removal of the membrane, if 
present, is highly spoken of, Except for this purpose there is no object 
in removing the membranes in the croupous variety, since these at once 
reform. When, after separation of the membranes or the slough, the 
conjunctiva has become strongly congested, soft, and succulent, and the 
secretion begins to be abundant, we may commence the application of 
a nitrate-of-silver solution, by means of which we bring the swollen con- 
junctiva more rapidly back to its normal state. In so doing we must 
at first proceed with great caution, use a pretty weak solution (one per 
cent) and discontinue the application at once if membranes or deep in- 
filtrations once more develop. 

[* In America severe cases of conjunctival diphtheria are ol rare occur- 
roncc. — D.] 



DISEASES OP THE CONJUNCTIVA. 



89 



We keep on making the applications to the conjunctiva as lon^ as 
the latter is red and swollen and discharges a copious secretion. If in 
the deep form after the subsidence of the disease partial necrosis and 
sloughing of the conjunctiva have set in, we try during the subsequent 
period of cicatrization to oppose, as far as possible, the formation of ad- 
hesions between the lids and the eyeball (doing this by frequently draw- 
ing the lid away from the eyeball or by laying a pledget soaked in oil 
between the two), for adhesions once formed can be removed only by 
an operation. Complications affecting the cornea are to be treated ac- 
cording to the rules that will be given further on for purulent inflam- 
mation of the cornea in general. 

All operative procedures, whether upon the cornea or upon the lids, 
should be avoided in the first stage, as the wounds thus produced gen- 
erally become diphtherial too. 

In consideration of the very infectious character of diphtheria, our 
special aim must be prophylaxis. While acute blennorrhcea and tracho- 
ma exert an infectious action only through a transfer of the secretion, 
infection in diphtheria can, in all probability, occur simply by means 
of the air, without any direct transfer. Accordingly, we remove from 
the vicinity of the patient all persons who are not indispensably neces- 
sary for purposes of nursing ; but, most of all, we insist upon the removal 
of children, who are particularly susceptible to infection. If diphtheria 
has attacked only one of the patient's eyes, the other must be protected 
against infection by a carefully applied occluding bandage, just as in 
acute blennorrhcea. 

The persons who have charge of the patient must be particularly 
enjoined to cleanse the hands carefully after touching the diseased eye, 
to destroy at once the materials employed in cleansing, etc. 

We owe the first exact description of conjunctival diphtheria to Von Graefe, 
who, in Berlin, had an opportunity of seeing many cases of this disease. His 
description relates to the deep variety, of which he distinguishes two groups 
of cases. In the first group— that of diphtheria en plaques — constituted by the 
lighter cases, the diphtherial spots in the conjunctiva are found under the 
form of large or small islands, which occur especially on the conjunctiva of 
the lids and between which lie areas of tissue that is not so much diseased. 
In the severer cases, on the other hand, the diphtherial foci rapidly coalesce, 
so that the entire conjunctiva becomes rigid and bloodless (confluent diph- 
theria). 

After Loffler had discovered in the membranes of pharyngeal diphtheria 
the bacillus that bears his name, it was soon after shown to be present in 
diphtheria of the conjunctiva also (Babes, Kolisko and Paltauf, and others). 
On the other hand, no one supposed that the cases in which a membrane forms 
upon the conjunctiva must also be regarded as diphtheria until the presence of 
the Lofller bacillus was demonstrated in them also (C. Frankel, Uhthoff, Elsch- 
nig, Escherich, Sourdille, Schirmer, and others). The same thing occurred in 
this case as in that of pharyngeal diphtheria and laryngeal croup, whose etio- 



90 DISEASES OP THE EYE. 

logical identity has only very recently been recognized. Many assume that 
membranous inflammation of a mucous membrane implies a feebler action of the 
diphtheria bacilli than does diphtheritic inflammation proper, the comparatively 
slight effect of the bacilli in the former case being due either to their having 
lost their virulence or to the patient's being more refractory to the influence. 
But apart from this, the severity of the inflammation is influenced by the fact 
that beside the Loffler bacillus there occur on the inflamed conjunctiva other 
germs, such as the staphylococcus and streptococcus. In fact, the streptococ- 
cus by itself is competent to produce a disease of the clinical aspect of con- 
junctival diphtheria; and in my clinic actually the severest cases were those in 
which the streptococcus alone was present, the slighter or croupous cases being 
associated with the Lofiler bacilli. 

Croupous Membranes on the Conjunctiva.— Croup and diphtheria are 
primarily anatomical terms denoting definite forms of inflammation. Croupous 
inflammation is characterized by the deposition of an exudate upon the surface 
of a tissue, where, by coagulation, it hardens into a membrane. The essence 
of the diphtheritic inflammation, on the contrary, consists in the exudation of a 
great mass of material within the tissue itself, together with consecutive necro- 
sis of the latter. Diphtheritic inflammation may be regarded as a croupous 
inflammation carried to a higher point, in so far as the same injurious cause 
may, when acting to a slight extent, produce a croupous, when acting to a 
greater extent, a diphtheritic inflammation of the mucous membrane. Sourdille 
has demonstrated experimentally that by painting the conjunctiva with am- 
monia one can at will produce either the croupous or the diphtheritic form of 
inflammation, according to the intensity, greater or less, with which the agent 
is applied. We meet with the same experience in our medical practice, when, 
by maliing too strong or too frequent applications of the silver solution to an 
inflamed conjunctiva, we produce a croupous coating upon it, and then, in spite 
of this result, keep on witli the application. In this case a diphtheritic inflam- 
mation with circumscribed necrosis of the tissue will ensue. Chemical irritants 
of an organic nature may bring about the same result. Thus the repeated appli- 
cation of the jequirity infusion produces first a croupous, afterward a diphthe- 
ritic inflammation. And, furthermore, the same thing holds good for many of 
those infliimmations of the conjunctiva that are caused by micro-organisms. 
Thus in an acute blennorrhoea, when the inflammation attains a high degree of 
severity, either a croupous coating or a diphtheritic infiltration of isolated por- 
tions of the conjunctiva may be observed, and such cases are often regarded as 
genuine diphtheria. 

Accordingly, the same clinical picture— e. g., that of a diphtheritic con- 
junctivitis—may be produced by the most various kinds of pathogenic agents, 
both of a chemical and a parasitic nature ; and, on the other hand, the same 
pathogenic agent — e. g., the Loffler bacillus— may give rise to a variety of clin- 
ical pictures — i. e., to both croupous and diphtheritic inflammation. It is not ten- 
able, therefore, as has hitherto been done, to employ the expressions croup and 
diphtheria of the conjunctiva both to characterize certain anatomical changes, 
and also to denote definite types of disease, each of single etiology. With re- 
gard to the expression diphtheritis, I have adhered to Roser's proposition, using 
the word diphtheritis as an anatomical term for that variety of inflammation in 
which the exudate undergoes coagulation within the tissue itself. On the other 
hand, diphtheria and diphtherial are used in an etiological sense to denote 



DISEASES OP THE CONJUNCTIVA. 91 

those affections which, whatever appearance they may present, are caused by 
the Loffler bacillus. The expression croupous conjunctivitis should be used 
simply as an anatomical term. 

Formerly most of the spontaneously developing conjunctivitides that were 
associated with the formation of a membrane were comprehended under the 
terms conjunctivitis cruposa or menibranacea, and thought to constitute a single 
independent disease. But recent bacteriological investigations have shown that 
the most various pathogenic agents may give rise to the formation of a mem- 
brane upon the conjunctiva. As far as is at present known, a croupous con- 
junctivitis may originate from the following causes: 

(a) Spontaneously developing croupous conjunctivitis. This usually runs an 
cuMte course, and is the kind that was formerly described under the name of 
conjunctivitis cruposa as a distinct disease. We have seen above that a part of 
these cases, being caused by the Loffler bacillus, are to be attributed to diph- 
theria. This knowledge is practically important, because we now know that 
even these apparently light cases of conjunctivitis may by transfer to others 
produce severe diphtheria of the conjunctiva or of the pharynx, and that we 
must consequently apply to them all customary precautionary measures. 

Croupous inflammations, in part of a serious character, are caused by the 
streptococcus (Terson, Bourgeois and Gaube, Debierre), and less severe kinds 
by the pneumococcus (Moras, Parinaud). Among the cases that run a light 
course belong also those of acute catarrh, that are produced by the bacillus of 
Weeks, and are associated with the formation of membrane (Morax) ; and that 
the acute blennorrhoea caused by the gonococcus not infrequently shows mem- 
brane foiTnation has already been stated above. 

To the cases of membrane formation upon the conjunctiva that pursue a 
more chronic course belong the very rare instances of herpes iris of the con- 
junctiva. These latter can readily be diagnosticated, provided the characteris- 
tic exanthem of herpes iris (a central reddened or pigmented area of skin sur- 
rounded by a wall of vesicles) is also to be found upon the skin. This, however, 
is not always present. Sometimes, too, a formation of membrane like that 
upon the conjunctiva occurs upon the mucous membrane of the mouth. In 
some cases the disease recurs frequently. In one case, which probably belongs 
here, Gerke and Kain isolated a coccus which, inoculated upon a rabbit's con- 
junctiva, produced a formation of membranes there. 

Furthermore, there have been described cases of peculiarly chronic forma- 
tion of membrane upon the conjunctiva— cases lasting for months, or even 
years— the nature of which is still doubtful (Arlt, Hulme, Morton, and 
others). 

(h) By the application to it of external irritants of a chemical nature the con- 
junctiva may be thrown into a state of inflammation with the foi mation of a 
membrane. As already mentioned, such irritant substances include bodies both 
inorganic and organic, like ammonia, nitrate-of-silver solution, and jequirity 
infusion. 

(c) Losses ofsuUtance in the conjunctiva (and the same thing is seen in other 
mucous membranes) verv soon become covered with a membrane of coagulated 
fibrin, under which the healing of the wound proceeds. This process is observed 
after operations (e.g., tenotomy), injuries, and also spontaneously developing 
wounds— as, for example, those occurring after rupture of pemphigus vesicles 
(see § 18). 



92 DISEASES OF THE EYE. 



V. Conjunctivitis Eczematosa.* 
17. Symptoms.— In its simplest, typical form, conjunctivitis ec- 
zematosa presents the following picture : A little red eminence, of 
about the size of a millet seed, develops at some point i^pon the limbus 
of the conjunctiva. This is the efflorescence (Fig. 28). In the be- 
ginning it is conical, its apex being covered by the epithelium of the 
conjunctiva. In a short time the epithelium at the summit of the 
efflorescence separates, and the tissue that lay beneath it breaks down, 
so that the apex of the cone, so to speak, melts away ; and the cone 




S 

Fig. 28. — Eczematous Efflorescence in the Limbus. Magnified 62 x 1. 

The sclera, S, is distinguished by its more dehcate fibrillation and its blood vessels from the more 
homogeneous, nonvascular cornea, H. The nodule is situated at a point corresponding to 
the boundary between the two membranes, but more over the sclera than over the cornea. 
It consists of densely packed round cells, between which the blood-vessels are recognizable 
under the form of hghter-colored strise. In the vicinitj^ of the nodule the vessels of the con- 
junctiva (c) and episclera (e) are bordered by extravasated leucocytes. The epithelium (.E) 
of the conjunctiva is bulged forward by the nodule, and at the apex of the latter is thinned, 
and, owing to the penetration of the round cells into the epithelial layer itself, has lost the 
sharp border ordinarily existing between it and the connective tissue. 

itself bears on its top a minute gray ulcer, which thus lies above the 
level of the neighboring, heavy conjunctiva. By a continuation of the 
breaking-down process the cone at length disappears entirely, the ulcer 
sinks to the level of the conjunctiva, and speedily becomes clean and 
then covered with epithelium. Thus the ulcer heals, without a visible 
mark being left upon the conjunctiva. 

As the efflorescence springs up, the adjacent part of the conjunc- 
tiva becomes hyperEemic, the injected vessels being directed from all 
sides toward the little nodule. Hence, the reddened portion of the 
conjunctiva shows the form of a triangular sector, the apex of which 
lies in the limbus and corresponds to the nodule. The remainder of 
the conjunctiva is perfectly free from congestion. 

* Synonyms : Conjunctivitis lymphatica (scrofulosa, phlyotffinulosa, pustulosa, 
exanthematica), herpes conjunotivBB (Stellwag). 



DISEASES OP THE CONJUNCTIVA. 



93 



The simplest type of conjunctivitis lymphatica, therefore, consists 
in the formation of a sharply circumscribed, nodular exudate, to which 
there corresponds an injected district of the conjunctiva. Conjunc- 
tivitis lymphatica is hence & focal affection of the conjunctiva of the 
eyeball, and is thus distinguished from all the varieties of conjunctival 
inflammation hitherto described which are diffused inflammations, in 
that they extend in a uniform fashion over large sections of the con- 
junctiva. 

The clinical pictures which conjunctivitis eczematosa actually ex- 
hibits present modifications of the type above described, which differ 
most widely from each other. These modifications concern — 

(a) The nvmber of the efflorescences. It is rare that we find but 
one of these ; generally there are several, and not infrequently a good 
many, present at the same time. The fewer they are the larger they 
generally grow ; in rare cases they almost attain the size of a lentil. 
AYhen there are many nodules present they are small ; often we find the 
entire limbus, or even the cornea itself, covered with very minute emi- 
nences, so that the surface of the eyeball looks as if fine sand had been 
strewn over it. Such very small nodules commoqly disappear in a few 
days by resorption, without any preliminary disintegration. When 
multiple efflorescences are present, the injected portions of the bulbar 
conjunctiva belonging to the separate nodules become confluent, and 
the conjunctiva then appears reddened all over, so that the focal char- 
acter of the disease is obscured, 
and declares itself only by the 
presence of separate nodular 
exudates. So, too, when the 
inflammation is great, the pal- 
pebral conjunctiva also par- 
ticipates in the injection, so 
that, in that case, conjunctivi- 
tis eczematosa is no longer an 
affection limited to the bulbar 
conjunctiva. 

(b) The site of the efflor- 
escences may be not only in 
the limbus itself, but also ex- 
terior to the latter, in the an- 
terior segment of the bulbar 
conjunctiva, and likewise in- 
terior to the limbus, in the cornea itself. In the latter are situated 
small gray nodules, which consist of an accumulation of round cells 
superficially disposed between Bowman's membrane (Fig. 39, B) and 
the epithelium (Fig. 29, U), which is bulged forward by them. By the 
breaking down of the nodule there is produced in the cornea a loss of 




Fis. 39.— Efflorescence on the Cobnea in Con- 
junctivitis Eczematosa. (After Ivvanoff.) 

The nodule, which consists of cells, lies between 
Bowman's membrane, B. and the epithelium, E, 
which latter is thus raised so as to form a prom- 
inence. In the epithelium we distinguish the 
lowermost layer of cylindrical cells, ti, the mid- 
dle layer of polygonal cells, m, and the upper- 
most layer of fiat cells, o ; scattered between the 
epithelial cells lie a few round cells, r. A nerve, 
n, is seen extending through the parenchyma of 
the cornea, C. and among the corneal corpuscles, 
K, up to the nodule. 



94 DISEASES OP THE EYE. 

substance, which is quite shallow, affects merely the epithelium, and 
heals without leaving a permanent opacity. Often, however, the affec- 
tion assumes a more serious form, from the fact that the exudations 
have a tendency to spread farther in the cornea, extending either into 
the depth of the latter or along its surface. If the infiltration extends 
through -Bowman's membrane into the parenchyma proper of the cor- 
nea, an ulcer is produced, when it breaks down, which penetrates more 
deeply and can even perforate the ftornea. In that case, after the ulcer 
heals, a permanent opacity remains. 

(c) The corneal ulcers which result from the efflorescences may 
assume a serpiginous character — that is, they may spread by a sort of 
creeping process along the surface of the cornea. " In this way is pro- 
duced the vascular fasciculus (Fischer), which is also called keratitis 
fascicularis. This affection begins by the development of a small ulcer 
out of an efflorescence at the rim of the cornea. After some days this 
ulcer becomes clean in its peripheral half — that is, in the part turned 
toward the corneal rim. At the same time, in accordance with the 
ordinary behavior of regressive corneal ulcers, blood-vessels develop, 
which run from the limbus to that edge of the ulcer that is healing, 
and which serve to keep up the process of cicatrization. But in the 
meantime, that margin of the ulcer that is toward the center has re- 
mained infiltrated and gray. Inasmuch as at this place the infiltration 
and the subsequent purulent disintegration keep on extending, the ulcer 
constantly advances toward the center of the cornea, while on its j)e- 
ripheral side it heals equally fast, and draws the blood-vessels after it. 
The vascular fasciculus accordingly appears as a narrow red band formed 
of blood-vessels (hence the name), and extending from the corneal 
margin some distance into the cornea. At its apex it bears a small gray 
crescent, the infiltrated, advancing margin of the ulcer. The arrest 
and recession of the process first occur when the ulcer is completely 
healed. Until this has taken place the vascular fasciculus can advance 
far into the cornea, to its center or even beyond it. The small ulcer, 
however, always remains superficial, and a perforation of the cornea due 
to it has never been observed. When the vascular fasciculus has at 
length come to a standstill, the vessels gradually disappear from it, and 
there only remains a superficial opacity of the cornea which corresponds 
in shape to the long-drawn-out form of the vascular fasciculus. This 
opacity never clears up again completely, and hence, when found at 
any time during the whole subsequent life of the patient, enables us to 
diagnosticate the previous existence of a vascular fasciculus. 

(d) The severest cases of conjunctivitis eczematosa are those in 
which the exudation, starting from in front, makes its appearance in 
the deep layers of the cornea as a diffused deep-lying infiltration. We 
then find the cornea occupied to a considerable extent by an opacity of 
a uniform gray or yellowish color, becoming fainter toward the edges. 



DISEASES OP THE CONJUNCTIVA. . 95 

This opacity is situated in the deep layers of the cornea ; and the sur- 
face of the cornea over it is dotted with minute spots. In the bad cases 
the infiltrate, originally gray, becomes more and more yellow, and 
finally breaks down into pus, so that an extensive loss of substance is 
produced in the cornea. In the benign cases, on the contrary, the in- 
filtrate gradually disappears again by resorption, and the cornea regains 
its transparency either wholly or in part. It is astonishing to what an 
extent even extensive infiltrates can undergo resolution. 

(e) Instead of appearing as separate circumscribed foci, the exudate 
may occur under the form of a continuous new formation of tissue 
upon the surface of the cornea — that is, under the form of pminiis. 
This is called pannus eczematosus, to distinguish it from trachomatous 
pannus. It does not, like the latter, show a predilection for the upper 
part of the cornea, but develops from any spot whatever upon the cor- 
neal margin. It is ordinarily thin and not very vascular, and is quite 
disposed to undergo complete resolution. 

Conjunctivitis eczematosa is generally accompanied by abundant 
lachrymation. Mucous or muco-purulent secretion, on the contrary, 
such as occurs in catarrh, is not present as a rule ; hence the lids do 
not ordinarily stick together in the mornings. The only exception to 
this is formed by those old cases in which the inflammatory process has 
passed over to the palpebral conjunctiva, and has thrown it into a state 
of concomitant catarrhal inflammation. 

The subjective symptoms consist of photophobia and spasm of the 
lids (blepharospasm). Slight in some cases, in others they reach an 
extraordinary pitch ; children creep into a dark corner of the room, 
bury their faces in their hands, and struggle so violently against any at- 
tempt at opening their eyes that the examination on the part of the 
physician is conducted under great difficulties. The intensity of these 
symptoms bears no deflnite relation to the severity of the disease; in 
fact, it is precisely in that form of corneal affection which spreads more 
extensively and penetrates more deeply that the evidences of irritation 
are often pretty slight. The annoyance suffered, contrary to what 
takes place in conjunctival catarrh, is, generally speaking, greater in 
the morning than in the afternoon and evening. 

Course and Prognosis.— A single typical efBorescence upon the 
limbus passes through all its phases up to complete subsidence in eight 
to fourteen days. If several efflorescences are present, the process of 
cure requires a proportionately longer time. ISTevertheless, the disease 
would not last so very long if it limited itself to a single attack. This, 
however, is but rarely the case. Usually, after a period of quiescence, 
or even before the first attack of inflammation has quite run its Course, 
the eye becomes red again, and new nodules shoot up in or near the 
limbus. Thus the disease may, with longer or shorter intermissions, 
last on for months or years. Its beginning occurs in childhood ; the 



96 DISEASES OP THE EYE. 

separate attacks, however, are often protracted until the time of 
puberty, or sometimes even later ; the affection being situated, now in 
one eye, now in the other, then in both at the same time. Finally, 
the attacks become less and less frequent, and at length cease alto- 
gether. 

The constant wetting of the lids by the tears frequently leads to 
blepharitis, to eczema of the skin covering the lids, and, as a conse- 
quence, to ectropion of the lower lid. Excoriations are frequently pres- 
ent at the external angles of the lids, and blepharophimosis often 
develops later on. 

The prognosis of conjunctivitis eczematosa is favorable, in so far as 
the eye is but rarely rendered entirely blind by it. Superiicial efflores- 
cences disappear without leaving a trace behind ; ulcers which penetrate 
into the parenchyma proper of the cornea leave permanent opacities, 
which, however, are in most cases thin and superficial (macule of the 
cornea). In persons who have gone through with many recurrences of 
conjunctivitis eczematosa the cornese often bear quite a number of such 
maculae as signs of past attacks. Thus the sight is impaired, the patients 
being often incapable of doing fine work. In addition to this, chil- 
dren, in consequence of the frequently repeated inflammations of the 
eyes, fall behind in their physical and mental development. So, even 
if conjunctivitis eczematosa only in exceptional cases leads to blindness, 
it nevertheless does so much harm to those who are attacked by it, that 
we ought to strive to combat it with every means in our power. 

18. Etiology. — Conjunctivitis eczematosa is one of the most fre- 
quent of eye disease's, and it has its origin in the scrofulous diathesis. 
Like the latter, it is a disease of childhood and youth. In very young 
children — those under the age of one year — it occurs but seldom, and 
it generally ceases at the time of puberty. Adults are attacked by it 
only ill case they have carried the disease along with them from their 
childhood. The enormous majority of children affected with conjunc- 
tivitis eczematosa belong to the poorer classes. Such children receive 
insufBcient and unsuitable nourishment, live in damp, poorly ventilated 
dwellings, and are kept constantly dirty. Other children aSected are 
those who, though once healthy, have become run down as a result of 
other diseases (scarlet fever, measles, typhoid fever, whooping cough, 
etc.). Such children as these look either pale and thin or bloated and 
flabby, like a sponge. The glands at the lower jaw, in the neck, and 
in front of the ear, are swollen. Partly as a result of the suppuration 
of these glands, and partly as a result of the breaking down of the 
scrofulous infiltrations in the skin, ulcers and fistulous passages are 
produced, which require months and years for their cure, and leave 
characteristic and disfiguring scars behind. Patches of moist eczema 
occur at various spots upon the body, most frequently upon the face • 
and the constant coryza from which many of these children suffer is 



DISEASES OF THE CONJUNCTIVA. 97 

to be attributed to an eczematous affection of the nasal mucous mem- 
brane. In the lids we find blepharitis. The nose and the i;pper lip 
are rendered thick by frequently recurring attacks of inflammation. 
More profound affections that occur are caries of bones (caries of the 
petrous bones appearing under the form of an otorrhoea being frequent), 
tuberculosis, and, in girls, delayed and irregular menstruation. 

Some one of the above-mentioned symptoms of scrofula, and often 
several of them at once, accompany most cases of conjunctivitis ec- 
zematosa. Sometimes, though rarely in comparison with the other 
cases, the disease is observed in an individual who otherwise is quite 
healthy, just in the same way that other indications of scrofula also 
occur at times as altogether isolated phenomena. 

Therapy. — In the lighter cases, the local treatment consists in the 
application of irritants, of which calomel and the yellow-precipitate 
ointment (Pagenstecher's ointment) are most in use. The calomel in 
a finely powdered state is sprinkled in a thin layer upon the conjunc- 
tiva of the lower lid by means of a camel's-hair brush ; the precipitate 
ointment (0.05 to 0.15 of yellow precipitate to 5 of fat), on the other 
hand, is introduced into the conjunctival sac by means of a glass rod 
or a brush, and is then rubbed about with the lids, so as to be dis- 
tributed over the whole conjunctiva. 

Both remedies are irritant in their action ; the precipitate ointment 
more so than the calomel. Hence, in the beginning of the disease, 
where the eyes are in a marked state of irritation, it is best to employ 
calomel; and subsequently, when the inflammatory symptoms are 
diminishing, to replace this by the yellow ointment. The remedies 
mentioned are to be applied only once a day. Both find a contrain- 
dication in the presence of recent infiltrates or progressive ulcers in 
the cornea. In such cases, before having recourse to irritant remedies, 
we must wait, meanwhile employing atropine, until the process of in- 
filtration has subsided or the ulcer has become clean. Pannus and 
vascular fasciculi do not contraindicate calomel or the yellow ointment. 
If under their use the vascular fasciculi can not be brought to a stand- 
still, we cauterize the advancing edge of the ulcer with the point of a 
delicate cautery iron (or with a galvano-cantery or thermo-cautery 
point). In the case of ulcers of larger size covered with exudation, as 
well as in the case of deep infiltration of the cornea, moist and warm 
compresses, applied several times a day for one or two hours at a time 
over the closed eyes, prove most efiicient. With regard to the treat- 
ment of deep ulcers and of the cicatrices that follow ulcers, the general 
rules set forth under the head of affections of the cornea are applica- 
ble. A bandage should be applied only in case of imperative necessity 
(e. g., when there are ulcers penetrating deeply into the cornea) ; other- 
wise its use had better be avoided. It hinders the ready escape of the 
tears which are so copiously secreted, and, as it very soon becomes wet 
7 



98 DISEASES OF THE EYE. 

through with the secretion, it is liable to set up eczema of the skin of 
the lids. 

In conjunctivitis eczematosa, general treatment, conducted with due 
regard to the etiology, is of especial importance. The child's nourish- 
ment should be strengthening and administered at regular hours. 
Care must be taken that the dwelling place be dry and well ventilated, 
and the child should be sedulously kept out in the open air, irrespec- 
tive of any photophobia that may exist. Indeed, in any case, we must 
not yield too much to this symptom of photophobia, and it would be 
quite a mistake to keep children in a dark room just because they shun 
the light. As invigorating measures, spongings with cold water are of 
service ; also a sojourn in the country, especially at the mountains or 
the seashore. After the acute inflammation has run its course, the use 
of brine baths or of sea baths is of great service in preventing relapses. 
Unfortunately, the carrying out of all these regulations is only too 
often frustrated by the force of circumstances and by the poverty of 
the patients. 

The medicinal treatment of scrofula consists in the administration 
of cod-liver oil and of the preparations of iodine, iron, arsenic, and 
quinine. The sort of remedy employed and its dose must be adapted 
to each individual case. Furthermore, the cure of the eye disease is 
favorably influenced by treating any coexisting scrofulous affections, 
especially blepharitis, and also eczema of the face and of the nasal 
mucous membrane. In these affections the application of white-pre- 
cipitate ointment (one to two per cent) does good service. In blepha- 
ritis this ointment is smeared at night over the closed palpebral fissure. 
Eczematous spots upon the face are covered with a pledget of linen 
smeared with the ointment, and, to relieve eczematous coryza, the oint- 
ment is introduced from the anterior nares as far into the nose as pos- 
sible and rubbed in. For relieving moist eczema of the face, we can 
also employ with great advantage a five to ten per cent nitrate-of-silver 
solution applied with the brush, after removal of the crusts, to the 
raw cutaneous surface, which thus becomes covered with a thin eschar, 
under which the raw spots heal rapidly. This application must be 
repeated at first daily, afterward at intervals of several days, and be 
kept up as long as crusts continue to form. 

The synonyms which are used for conjunctivitis eczematosa, such as con- 
junctivitis phlycteenulosa, conjunctivitis pustulosa, herpes conjunctivse (Stell- 
wag), originate from the view that the efflorescence on the conjunctiva or cornea 
is a hollow vesicle filled with fluid ((jAvKTaiva [bladder], pustula, lieipes vesicle). 
But the efflorescence is in reality never a vesicle, but a solid, though soft, projec- 
tion, whicli is formed chiefly by an accumulation of lymphoid cells (Figs. 38 
and 39). The softening and liquefaction of this cellular mass do not begin in 
the interior of the projection, but at its apex, so that there is no formation of 
a cavity (vesicle or pustule), but a loss of substance (ulcer) occurs, lying upon 



DISEASES OP THE CONJUNCTIVA. 



99 



the free surface at the apex. The name herpes cornefB, moreover, can give 
rise to a confusion with true herpes corner (herpes febrilis and herpes zoster, 
see § 40). 

In accord with the precedent set by the older authors, I formerly denoted con- 
junctivitis eczematosa under the name of conjunctivitis lymphatica (or scrofu- 
losa) on account of its undeniable connection with scrofulosis. Now, following 
many recent authors, I replace this etiological term by that of conjunctivitis 
eczematosa, which is indicative of the pathological anatomy of the disease, and 
thus denotes the nature of the morbid process. I do so because there are in- 
creasing indications for considering this affection of the conjunctiva as analo- 
gous to eczema of the skin. The latter, under the form of moist eczema, is, like 
conjunctivitis eczematosa, found particularly often in scrofulous children, being 
present especially upon the face and upon the edges of the eyelids themselves 
(blepharitis ulcerosa); and the nasal mucous membrane is also frequently at- 
tacked by it. This simultaneous occurrence on the skin and in the eye denotes 
in many cases a common origin from the scrofulous diathesis that is present ; 
but in other cases it is probable that the eczema develops in one spot and has 
been transferred from it to the other — i. e., from the skin to the eye or from the 
eye to the adjacent skin. Even in adults who have been attacked by a very ex- 
tensive eczema I have several times seen inflammations of the eye develop in 
the course of the disease, which were associated with marginal infiltrates of the 
cornea, and even led to perforation, and which therefore presented the picture 
of a severe conjunctivitis eczematosa. 

A certain proof of the identity of conjunctivitis eczematosa with ecze- 
ma of the skin will not be forthcoming until the same pathogenic agent has 
been proved to exist in both diseases. Up to the present time observers have 
been disposed to regard the staphylococcus pyogenes aureus as the agent 
in question, but further investigations are requisite in order to determine this 
point. 

The authors separate the eczematous aUeotions of the conjunctiva from those 
of the cornea; they speak of conjunctivitis and of keratitis eczematosa or 
phlyctfenulosa, of herpes of the conjunctiva and of the cornea, according as the 
efflorescence is located upon the conjunctiva or the cornea. In this way, for 
mere love of system, a picture of disease that, clinically speaking, is a perfect 
whole, is torn in two. In fact, we have here really but one single disease, which 
is localized sometimes in one place, sometimes in another. Frequently enough 
we find in the same eye, at the same time, an efflorescence in the conjunctiva; 
a second in the limbus, half in the conjunctiva and half in the cornea; and a 
third upon the cornea itself. Hence, in the foregoing description of the dis- 
ease the expression conjunctivitis eczematosa is employed for the disease in 
general, no matter upon what part of the surface of the eyeball it is localized. 
This can be done without doing violence to anatomy, inasmuch as the outer- 
most layer of the cornea must be looked upon as the continuation of the con- 
junctiva over the cornea. Accordingly, we can regard the involvement of the 
cornea in conjunctivitis eczematosa as an involvement of the "conjunctival 
layer " of the coi-nea. For the same reason pannus trachomatosus we regard as 
one of the symptoms of conjunctivitis trachomatosa, and not as an independent 
affection of the cornea. 

The differential diagnods between conjunctivitis eczematosa and the other 
affections of the conjunctiva and cornea is, as a rule, easily made. The char- 



100 DISEASES OF THE EYE. 

acteristic mark of the former lies in the focal character of the affection as well 
as in its localization upon and immediately about the cornea. Only one other 
variety of conjunctivitis, the conjunctivitis ex acne, shares this peculiarity with 
conjunctivitis eczematosa; but that disease is readily distinguished from the 
latter by the accompanying acne rosacea upon the face (see infra). In vernal 
catarrh (§ 30) also little nodules occur upon the limbus, but never break down 
into ulcers; moreover, the palpebral conjunctiva, too, is diseased, and in a 
characteristic fashion. Of the diffuse inflammations of the conjunctiva, 
catarrh might be confounded with conjunctivitis eczematosa. For in intense 
and obstinate cases of conjunctivitis eczematosa the affection spreads to the 
palpebral conjunctiva, which may become very much reddened, swollen, or 
even velvety ; in that case a mucous or muco-purulent secretion forms upon the 
conjunctiva. It is often diflScult to distinguish between such cases and catarrh, 
especially if just at the moment of examination there are no characteristic efBo- 
rescences present upon the conjunctiva of the eyeball. Fortunately, a mistake 
in diagnosis does no harm, since, with such a condition of the conjunctiva 
existing, gentle cauterization with the nitrate-of-silver solution is always indi- 
cated, no matter what the origin of the disease. The pustular form of acute 
conjunctival catarrh forms a sort of intermediate stage between catarrhal con- 
junctivitis and conjunctivitis eczematosa (see page 48). 

Eczematous pannus is to be chiefly distinguished from pannus trachomatosus 
by the fact that an exact examination of the conjunctiva of the lids and of the 
fold of transition either discloses the changes of traclioma or establishes the 
fact of their absence. In regard to corneal ulcers which have been preceded by 
the efflorescences of a conjunctivitis eczematosa, it is sometimes impossible to 
recognize the fact of this origin with certainty, except when the ulcer is located 
at the very margin of the cornea and extends into the limbus conjunctivae, 
corneal ulcers as peripherally situated as this occurring only in connection with 
conjunctivitis eczematosa. The vascular fasciculus can readily be confounded 
with an ordinary corneal ulcer, to which, in tlie course of healing, vessels have 
made their way from the limbus so as to form a reddish-colored bridge be- 
tween the limbus and the ulcer. In such a case there is no fear of the ulcer's 
extending into the pupillary area of the cornea, and, after the ulcer heals, only a 
small, rounded macula is left, and not a long, opaque stria, as in the case of the 
vascular fasciculus. The distinction between these two affections can be made 
as follows : In the vascular fasciculus, the advancing margin of the ulcer, in- 
filtrated with gray, is readily visible; the blood-vessels as they run up to it 
lie in the furrow which the ulcer has channeled in the course of its progress — 
lie, therefore, at or below the level of the corneal surface. In the case of a 
simple ulcer with which a development of vessels has been associated, this fur- 
row and the opacity corresponding to it are wanting. 

In the treatment of conjunctivitis eczematosa calomel plays the greatest 
part. Since this remedy under its own form is insoluble in water, it was at first 
believed that a purely mechanical action should be ascribed to it (a scratching 
open of the efRorescenees, which were considered to be vesicles). But opposed 
to this view is the fact that indifferent powders, for instance, finely pulverized 
glass, which were also employed for inspersions, did not develop the same 
action. More recent investigations have proved that the action of calomel is a 
chemical onv. The calomel powder, when sprinkled into the eye, remains a 
long time in the conjunctival sac ; minute quantities of it are transformed by 



DISEASES OF THE CONJUNCTIVA. XOl 

the sodium chloride contained in the tears into corrosive sublimate,* which is 
thus continually being formed in small quantities, and exerts a steadily con- 
tinued action upon the conjunctiva. According to others, calomel itself is, to 
a small extent, soluble in a salt solution such as the tears represent, and is hence 
efficient under its own form. It -we undertake the inspersion of calomel in 
patients to whom at the same time iodine is being administered internally, we 
not infrequently observe a strong corrosive action from the calomel ; for the latter 
forms with the iodine excreted in the tears the very corrosive mercuric iodide 
(Schlafke). These two remedies, therefore, are incompatible with each other. 

A symptom that is especially tormenting for the patients is the photopTioUa 
30 often connected with conjunctivitis eczematosa. In many cases this persists 
obstinately for mouths. The parents then bring the children to the physician, 
with the statement that they have been "blind " for such or such a number of 
weeks. The children offer the greatest resistance to the forcible opening of the 
eyes, especially when there are excoriations at the external commissure, which 
give pain and are prone to bleed when the lids are separated. Hence, in such 
cases the palpebral fissure is to be opened cautiously and not too wide, so as to 
avoid making the struggles of the children still greater. The lids, and espe- 
cially the upper lid, are rendered oedematous by the constant blepharospasm, 
because the veins of the lids, which pass between the fibers of the orbicularis, 
are compressed by persistent contraction of this muscle. Furthermore, a state 
of inversion of the lids (entropion spasticum) may be induced by this forcible 
squeezing together of the eyelids. Finally, cases have been described in which 
children who have suffered for a long time from blepharospasm were perfectly 
blind after the disappearance of this symptom (Von Graefe, Schirmer, Leber, 
and others). Such blindness is transient. As in most cases no objective 
changes were demonstrable as the cause of the blindness, no positive expla- 
nation for it can yet be assigned. 

In most cases the blepharospasm soon yields if the conjunctival trouble, 
which forms the basis of it, has been ameliorated by appropriate treatment. 
In case the spasm of the lid is particularly obstinate, Arlt's ointment (0.5 
gramme of extract of belladonna to 5 grammes of blue ointment) may be 
rubbed into the patient's forehead and temples two or three times a dayj 
Instillations of cocaine, pretty frequently repeated, or douching the entire 
surface of the body with cold water every day, are also frequently of efficacy. 
Finally, we can even perform the operation of splitting the external com- 
missure (canthoplasty, see § 168), especially when the palpebral fissure has 
been abnormally contracted by reason of blepharophimosis. 

Herz has called attention to the -fact that many children who suffer from 
conjunctivitis lymphatica are infested with head lice, and that after doing away 
with these vermin the conjunctival disease, which hitherto may have been, 
obstinate, often heals with surprising rapidity. This is owing to the fact 
that head lice are among the most frequent causes of eczema of the hairy scalp. 



Beside eczema, the following exanthemata, both acute and chronic, are asso- 
ciated with diseases of the conjunctiva. 

[* According to some, however, calomel can remain in contact with tear fluid 
for an indefinite time without change. — D.] 



102 DISEASES OP THE BYE. 

(a) Acute Exanthemata. 

Measles is regularly associated with a conjunctivitis. This appears under 
the form of an acute conjunctival catarrh, develops early (before the eruption 
of the exanthem upon the skin), and generally disappears of itself after two or 
three weeks without leaving any bad consequences behind. 

Only in exceptional instances does the conjunctivitis of measles take on a 
blennorrhoeal or even a diphtheritic aspect (without actually turning into true 
blennorrhoea or diphtheria). In such cases the cornea is endangered. During 
convalescence in some cases of measles, when the conjunctival inflammation 
had already become pretty slight, I have observed numerous Meibomian glands, 
both on the upper and the lower lids, becoming inflamed and suppurating (hor- 
deola meibomiaua, see § 108). The purulent contents were evacuated partly 
through the orifices of the glands, partly upon the inner surface of the lid after 
breaking through the tarsus and the conjunctiva. 

In variola, smallpox pustules not infrequently develop upon the conjunc- 
tiva, generally upon the tarsal conjunctiva near the intermarginal line. Small- 
pox pustules which develop upon the conjunctiva of the eyeball near the lim- 
bus are dangerous from their setting up a purulent keratitis in the adjacent 
part of the cornea — a condition which should not be confounded with the ulcus 
serpens that develops metastatically in smallpox (see § 36). 

(J) Chhonic Exanthemata. 

(1) Acne Rosacea Conjunctiva. — This disease of the conjunctiva, described 
by Arlt, begins as follows : A minute nodule forms, with moderate symptoms 
of irritation, upon the limbus. This efflorescence breaks down after some days, 
and the ulcer thus produced heals without leaving any visible cicatrix behind. 
This affection bears the greatest resemblance to the simple typical picture of 
conjunctivitis eczematosa, and shares with the latter its peculiar tendency to 
frequent recurrence. On this account it is very tormenting to the patient. It 
is possible to make the differential diagnosis chiefly from the fact that conjunc- 
tivitis ex acne attacks only adults and those who are at the same time affected 
with acne rosacea. It is important to make the correct diagnosis, since other- 
wise we might labor in vain to prevent the recurrences — a thing which can be 
done only by a suitable and long-continued treatment of the acne rosacea. 
The conjunctivitis itself is most speedily cured by inspersions of calomel. 

(3) Pemphigus Conjunctiva. — In this disease the conjunctiva, although red- 
dened as a whole, displays one or two spots that are deprived of their epithe- 
lium and covered with a gray coating. While these spots are slowly undergo- 
ing cicatrization — a process attended with shrinking of the subjacent conjunctiva 
— spots of the same nature appear in other places. Thus there is produced a 
constantly increasing cicatricial contraction of the conjunctiva, whose progress, 
it is true, is very slow (extending over months and years), but is irresistible. 
The conjunctiva becomes whitish, cloudy, and tense. First, the folds of transi- 
tion vanish, then folds make their appearance, stretching in a vertical direction 
from the lids across to the eyeball, and finally the lids are retracted so that 
trichiasis results. The conjunctiva at the same time grows continually drier 
and the lachrymal secretion dries up, owing to the fact that the excretory ducts 
of the lachrymal gland become occluded by the shrinking of the conjunctiva. 
Ulcers form upon the cornea, which later gets to be clouded all over, and 



DISEASES OP THE CONJUNCTIVA. 103 

like-wise dry upon its surface. In the bad cases the lids at length become com- 
pletely adherent to the eyeball, so that the cornea is permanently covered by 
the lids and the eye is incurably blind (symblepharon totale). Hence, the 
prognosis of pemphigus is very unfavorable — the more so as both eyes are 
always attacked. 

In pemphigus of the conjunctiva, contrary to vfhat happens in pemphigus 
of the skin, bullae are only exceptionally found, their place being taken by 
denuded areas in the conjunctiva. This is explainable from the anatomical 
character of the latter. Its epithelium is so soft and delicate that it can not, 
like the epidermis, be lifted up in broad layers by serous exudation, but 
ruptures and is thrown off in the form of shreds ; hence the raw spots 
upon the conjimctiva, which soon become covered with a gray coating, as is 
so frequently the case in wounds of mucous membranes. 

Pemphigus of the conjunctiva is usually found in conjunction with erup- 
tions of pemphigus upon the skin. Still more frequently there exists with the 
pemphigus of the conjunctiva an analogous affection of the mucous membrane 
of the mouth, throat, or nose. In these localities the pemphigus runs a course 
like that in the conjunctiva and may, particularly in the buccal cavity, lead to 
shrinking of the mucous membrane, and thus to stenosis of the mouth. But it 
may also happen that a lesion of the kind just described exists in the conjunc- 
tiva without pemphigus being present elsewhere in the body. That such cases 
as these, which were first described by Von Graefe as essential" phthisis of 
the conjunctiva, are also to be ascribed to pemphigus, is not certain, though 
probable. 

Treatment has no power to restrain the process. Arsenic is administered 
internally for the pemphigus ; and to make the patient easier, mucilaginous 
remedies are instilled into the eyes as in xerophthalmus (see page 76). Trans- 
plantation of pieces from another mucous membrane into the conjunctival sac 
may be tried in order to replace the conjunctiva that has been destroyed. 

(3) Lupus Cojstjunctiv^. — Lupus of the skin sometimes is continued over the 
edges of the lids upon the conjunctiva. In this situation it appears as an ulcer, 
the bottom of which is covered with granulations in which tubercle bacilli can 
be made out. Lupus of the conjunctiva must therefore be regarded as a tuber- 
culous disease, for which reason reference for further details must be made to 
the article on tuberculosis of the conjunctiva (§ 20). 

In the case of other exanthemata, too, for instance in macular and papular 
syphilides, in pityriasis, psoriasis, ichthyosis, herpes iris, dermatitis herpeti- 
formis, lepra, etc., the conjunctiva is sometimes characteristically implicated. 
In lepra, nodules generally develop near the margin of the cornea, and subse- 
quently grow down into the subjacent sclera and also upon the cornea; when 
upon the latter they not infrequently have the appearance of a new growth. 
There is an associated iritis sometimes combined with the formation of lepra 
nodules in the iris ; also cyclitis. The nodules in the difierent parts of the eye 
finally break down, and the eye is lost. 

VI. Vernal Cataerh. 

19. Symptoms and Course. — Vernal catarrh (Saemisch) is a chronic 
disease, persisting for years and setting up very characteristic changes 
in the conjunctiva, both of the tarsus and of the eyeball. The con- 



104 DISEASES OF THE EYE, 

junctiva of the tarsus is covered witli papillae, which are broad and 
flattened, so as to make the conjunctiva appear like a pavement of 
cobble-stones. Over the whole lies a delicate, bluish-white film, as 
if a thin layer of milk had been poured over the conjunctiva. The 
changes in the conjunctiva of the eyeball are still more striking, 
although not so constantly present. Growths arise from the limbus 
at the outer and inner side of the cornea, under the form of brownish, 
uneven, hard nodules of gelatinous appearance. These extend partly 
into the transparent cornea for a short distance, and still farther in the 
opposite direction into the conjunctiva. In contradistinction to the 
nodules of conjunctivitis eczematosa, which break down so speedily, 
these nodules never ulcerate ; on the contrary, they are very stable 
bodies, often lasting for years with but slight variations in size. 

Quite as characteristic as the changes objectively perceptible are the 
statements given by the patients. They say that during the winter 
they experience little or no annoyance from their eyes, but as soon as 
the first warm days come in spring the eyes begin to grow red and to 
water ; the patients are greatly tormented by photophobia, and espe- 
cially by a constant itching in the eyes. The warmer the weather, the 
greater the intensity of the subjective troubles ; conversely, the patients 
feel easier if, for instance, there occur in summer a series of cool, rainy 
days. In autumn the troubles once more abate, and during the cold 
season they disappear completely, only to begin anew in the following 
spring. The difference in the objective condition at different seasons 
of the year is considerably less than one would suppose from the great 
change in the patient's subjective state, and consists principally in the 
eyes being free from discoloration in winter and injected in summer, 
while the growths upon the conjunctiva appear but slightly smaller in 
winter than in summer. 

Vernal catarrh is a pretty rare disease, chiefly affecting the male 
sex and the ages of boyhood and youth. Many patients seem to be 
in other respects quite healthy, while others, without being scrofulous, 
display besides pallor of the complexion multiple swellings of the lym- 
phatic glands, especially on the neck and lower jaw. Almost always 
both eyes are attacked. The disease generally keeps on making its 
return annually for three or four years, and often longer still, for ten 
or even twenty years, until finally it becomes extinct, without leaving 
any marked trace of its presence behind. The prognosis is therefore 
good as regards the ultimate outcome, but bad as regards the duration, 
as up to the present time we know of no remedy for curing the disease 
or for preventing its annual return. The cause of the disease is 
unknown. 

Inasmuch as we are unable to cure the disease, the treatment must 
be limited to the amelioration of the subjective symptoms. We com- 
bat the inflammation with the remedies used for acute and chronic con- 



DISEASES OP THE CONJUNCTIVA. 105 

junctival catarrh. For the itching and photophobia, cocaine in two- 
per-cent sohition may be instilled. If the growths are of a considerable 
size they may be removed. 

Vernal catarrh is not a catarrh, as the not altogether suitable name choseu 
for it -would indicate, but is a disease sui generis. It was first described by 
Arlt (1846), who regarded it as a peculiar variety of conjunctivitis eczematosa. 
Subsequently Desmarres mentioned it under the title " hj'pertrophie perik^ra- 
tique," Von Graefe as gelatinous thickening of the limbus, Hirschberg as 
phlyctajna pallida. Saemisch first brought into prominence the characteristic 
exacerbation of the disease during the warm season, and therefore called it 
vernal catarrh, by which name it is at present commonly designated. Horner 
discovered the peculiar character of the tarsal conjunctiva, and thus completed 
the picture of the disease. 

The papillfB on the tarsal conjunctiva are hard — sometimes as hard as car- 
tilage. They are found to consist of a sort of areolar connective tissue, with a 
peculiar, hyaloid degeneration of the cells of the connective tissue and of the 
vessels. The epithelium covering the papillse is thickened, and to this is prob- 
ably due the macroscopically visible bluish-white film upon the surface which 
is characteristic of the disease. The growths upon the limbus consist of con- 
nective tissue, which is provided with very many cells and blood-vessels. Here, 
also, the epithelium is greatly thickened, and in places penetrates into the parts 
below, under the form of solid epithelial plugs (Horner, Vetsch). The growths 
are separated from the healthy cornea by sharply defined borders. In the 
cornea a slender gray stria, resembling the arcus senilis, may be seen, which 
runs parallel to the margin of the nodule, and is separated from it by a slender 
strip of transparent cornea. 

In the lightest cases of vernal catarrh it often happens that all the symp- 
toms are not present. Most frequently it is the growths upon the limbus that 
are wanting, the changes upon the tarsal conjunctiva alone being found. The 
latter are, hence, more important for the diagnosis of the disease. But there 
are also cases in which just the reverse occurs, i. e., tlie limbus is thickened, 
but the conjunctiva of the lids shows no characteristic changes. Some- 
times the only thing to indicate the presence of the disease is a peculiar, 
constant, tawny redness of the eyeball, made up of a coarse, reticulate conjunc- 
tival injection, combined with an evident ciliary injection. In such doubtful 
cases the diagnosis can be established only by the history, the specially char- 
acteristic features of which are the itching and the dependence of the symp- 
toms upon the external temperature. 

In severe cases the growths upon the limbus sometimes reach a considerable 
extent. They may even go entirely round the cornea, so that the latter is en- 
circled by a high, hard wall. In two cases I have seen the cornea itself quite 
extensively attacked by the morbid process. The first case was that of a six- 
teen-year-old boy, in whom a layer resembling a pannus, but pale, gelatinous- 
looking, and devoid of vessels, shot out over the cornea from the thickened 
limbus. In spite of all attempts to check by therapeutic measures the progress 
of the growth, the whole cornea was ultimately covered by it, and remained 
permanently clouded. In the second case, a Greek of thirty years of age, an 
analogous growth took place on the cornea of both eyes, although it did not 
cover the cornea completely, but left free on both sides a small central area, 



106 DISEASES OP THE BYE. 

about corresponding to the size of the pupil. According to Van Millingen, 
such cases not infrequently come under observation in Constantinople, where 
the disease appears to occur much more often than it does here. 

The second case is also of interest because it concerned a grown man, while 
the disease ordinarily occurs only in youth. Quite small children are also 
exempt from it; there is only one instance of a one-year-old child being 
observed to suffer from the disease. 

The growths in the limbus might lead to a confusion of vernal catarrh with 
conjunctivitis eczematosa, the papillas upon the conjunctiva tarsi to a confusion 
with trachoma. The growths in the limbus are distinguished from the efflores- 
cences in conjunctivitis eczematosa, apart from their external appearance, 
chiefly by their unchangeable character during even a prolonged course of 
observation. The papillary outgrowths are most of all distinguished by their 
bluish-white coating, which is wanting in papillary trachoma. The history of 
the case is also of special importance in making the differential diagnosis. 
The extremely characteristic statements in regard to the fact of a return of the 
disease every year in the spring often establish the correct diagnosis before 
we have even looked at the eye. In hay fever, to be sure, there is also gener- 
ally a return of the conjunctivitis every year in the spring (see page 48). But 
this recurrence is an acute one, and runs its course within a few weeks, while, 
on the contrary, the symptoms of vernal catarrh last during the whole of the 
warm season. 

In the treatment of vernal catan-h I have found the instillation of a three- 
per-cent solution of boric acid and the inunction of a one to two per cent oint- 
ment of white precipitate, as recommended by Arlt, to be the most efficient 
means for alleviating the patient's sufferings. For the relief of the itching I 
often and with success use Van Millingen's prescription of dilute acetic acid 
(one drop of acidum aceticum dilutum to ten to twenty grammes of water) in- 
stilled into the eye several times a day. 

If the patient is one of the kind with pale face and swollen lymphatic 
glands, the exhibition of arsenic and iron internally is advisable. 

Amyloid Degeneration op the Conjdnotiva.— This rare disease has 
hitherto been observed only in Russia and the countries adjacent, and was first 
described by Oettingen in Dorpat. It consists in a peculiar degeneration of the 
conjunctiva, by reason of which the latter becomes yellowish, translucent like 
wax, nonvascular, and very friable. With this there is associated a consider- 
able thickening of the membrane, so that it forms large swellings which look 
like new growths. The affection begins in the retrotarsal fold, and from this 
passes over to the conjunctiva of the eyeball and of the lids ; in the lids the 
tarsus also is subsequently implicated in the degeneration. In a case that has 
lasted a long time the following clinical picture is found : The patient can not 
open the eye because the two lids, transformed into large, misshapen swellings, 
cover it up. If the lids are drawn as far apai-t as possible, the waxlike con- 
junctiva is seen rising up under the form of a rigid prominence all about the 
cornea, which latter is either clear or is covered by pannus. Thick swellino-s 
belonging to the retrotarsal fold, protrude between the lids and the eyeball ; 
the plica semilunaris also is enlarged until it forms a misshapen mass. These 
various swellings are so friable that they often tear when an attempt is made 
simply to separate the lids for examination, although in so doing they bleed 



DISEASES OF THE CONJUNCTIVA. 107 

very little. The disease runs a very chronic course, dragging on for years 
without any real inflammatory symptoms, until at length the patient is deprived 
of the use of his eyes by his inability to open the misshapen lids. 

Microscopic examination has shown that the degeneration of the conjunc- 
tiva originates from the subconjunctival cellular tissue. This at first is found 
to be very abundantly infiltrated with cells (adenoid proliferation). This is 
followed by the formation in the tissues of dully lustrous, homogeneous bodies, 
which are called by the name either of amyloid or of hyalin, according to the 
reaction that they give with stains. Hyalin may occur as a preliminary stage in 
the development of amyloid; but generally it represents a variety of tissue 
degeneration {hyaline degeneration of the conjunctiva) distinct from the amyloid, 
and showing no tendency to pass over into the latter. Hyaline and amyloid 
degenerations present almost precisely the same clinical picture, so that a posi- 
tive distinction between the two can be made only by examining excised pieces 
of conjunctiva. Finally, calcification or ossification may take place in the 
degenerated mucous membrane. 

The disease attacks people in middle life, and ordinarily both eyes are 
affected. Very frequently amyloid degeneration is preceded by trachoma of 
the conjunctiva, which, however, should not be regarded as the cause of the 
affection, inasmuch as the latter can develop in eyes that previously were 
healthy. The actual cause of the disease is not known. In every instance it is 
a purely local process, for the individuals attacked by it are sound as far as the 
rest of the body is concerned, and do not suflier from amyloid degeneration of 
the internal organs, with which, therefore, amyloid degeneration of the con- 
junctiva has nothing at all to do. 

Medical treatment is powerless against this disease. We must confine our- 
selves to removing the growths upon the conjunctiva to such an extent that the 
lids can be opened and vision thus rendered possible. It is by no means neces- 
sary, indeed it is not at all advisable, to remove by a radical operation all the 
diseased parts, since the portion of the growth that is left behind generally 
atrophies of itself afterward. 

VII. TUBEKCULOSIS OF THE CONJUNCTIVA. 

20. In the conjunctiva tuberculosis ordinarily appears under the 
guise of ulcers. Tuberculous ulcers are located as a rule in the tarsal 
conjunctiva. TJie diseased lid even on external inspection looks thick- 
ened. In everting the lid there appears upon its conjunctival surface 
an ulcer which is either covered by grayish-red granulations, or has a 
yellowish-red, lardaceous-looking base. In its vicinity small gray nod- 
ules (tubercle nodules) or outgrowths resenabling a cock's comb are 
often found in the conjunctiva. The ulcer shows no disposition to 
heal ; on the contrary, it spreads, although it does so very slowly. It 
may pass over to the conjunctiva of the eyeball ; and even the cornea 
is sometimes covered over by a sort of pannus. In especially severe 
cases the ulcer does not remain confined to the conjunctiva, but eats 
through the entire thickness of the lid, so that even on external ex- 
amination a deficiency of tissue is observable in the lid. Quite early in 
the disease the lymphatic gland in front of the ear becomes swollen ; 



108 DISEASES OP THE EYE. 

afterward, the lymphatic glands about the lower jaw and in the neck 
also become enlarged. The clinical picture aSorded by the disease is 
thus pretty characteristic, although the diagnosis is to be considered as 
established only when fragments of tissue have been removed from the 
ulcer, and tubercle bacilli have been proved by the ordinary methods to 
exist in them, or when tuberculosis of the iris can be produced in rab- 
bits' eyes by inoculation with fragments of this sort. 

Tuberculosis of the conjunctiva generally attacks only one eye. 
The patient does not suffer pain; it is only by the swelling, of the lid, 
the purulent secretion, and subsequently by the diminution of visual 
power, that he is annoyed and made aware of the existence of his 
trouble. The disease occurs, almost without exception, in young peo- 
ple, and runs an uncommonly chronic course, being often protracted 
over many years. Even after an apparently radical cure it shows a 
great tendency to recur, and it can, by infecting the rest of the organ- 
ism, iinally lead to the patient's death from tuberculosis. The treat- 
ment in the cases where a complete removal of all the diseased parts 
seems still possible consists in the radical excision or curetting of the 
ulcer with a subsequent thorough cauterization, of the raw surface. The 
wounds made by the operation are s.trewn every day until they are com- 
pletely healed with finely powdered iodoform, a remedy which just in 
tuberculous processes is of particular efficacy. In some cases a cure has 
been effected by the injection of Koch's serum. 

Tuberculosis and lupus of the conjunctiva are to be looked upon as affections 
which are identical in their essential character, in so far as both represent ulcer- 
ative processes which are produced and maintained by the presence of tubercle 
bacilli. In fact, the first cases of tuberculous ulcers of the conjunctiva were 
described as primary lupus of the conjunctiva (that is, lupus of the conjunctiva 
without any coincident lupus of tlie skin) (Arlt). The two processes are dis- 
tinguished only by external points of difference relating to their outward aspect 
and their course. Thus, as a rule, lupous are distinguished from tuberculous 
ulcers of the conjunctiva by the fact that they have migrated from the skin to 
the conjunctiva, and that, like lupus of the skin, they show a spontaneous cicatri- 
zation on one side, while on the other the ulcer keeps advancing (see also p. 103). 

Tuberculosis of the conjunctiva may be primary or secondary. It is pri- 
mary if no sign of tuberculosis is present in the rest of the body at the time 
when the affection of the conjunctiva begins. In that case tuberculosis of the 
conjunctiva represents a purely local affection which has, without doubt, been 
excited by direct infection of the cdnjunctiva. A particle of dust containing 
bacilli gets into the conjunctival sac, and with its sharp angles produces a small 
superficial lesion of -the conjunctiva which is thus infected (tubercle bacilli, ac- 
cording to the researches of Valude, not penetrating into the conjunctiva when 
the epithelium is intact). In favor of an infection of this sort is the fact that 
we see tuberculous ulcers so frequently beginning in the region of the sulcus 
subtarsalis, where small foreign bodies are most readily retained. Some cases 
of primary tuberculosis have also been described, which originated in the con- 
junctiva bulbi and even in the cornea itself. 



DISEASES OP THE CONJUNCTIVA. 109 

Primary tuberculosis of the conjunctiva may remain for a long time confined 
to the latter; indeed, in exceptional cases it may even heal spontaneously. The 
rule, however, is for tuberculosis to spread from here to the other parts of the 
organism. This extension may take place by way of the lymphatic circulation, 
the neighboring lymph glands becoming first affected with tuberculosis. Or, 
the disease may extend by continuity, the lachrymal passages first and subse- 
quently the nasal mucous membrane being infected by means of the tears which 
contain bacilli. 

Those cases of conjunctival tuberculosis are to be regarded as secondary in 
which either there is at the same time an evident tuberculosis of the internal 
organs (especially of the lungs) or in which tuberculosis is transmitted to the 
conjunctiva from places in its vicinity. A tuberculous affection of the nasal 
mucous membrane may be transferred to the conjunctiva by way of the lachry- 
mal passages. Not infrequently, therefore, we find conjunctiva, lachrymal sac, 
and nasal mucous membrane attacked at the same time by tuberculosis, and a 
careful study of the history of the case and an exact examination generally ren- 
der it possible to make sure whether the affection has passed down from the 
conjunctiva to the nose or vice versa. 

It is of the greatest importance for the prognosis and treatment to deter- 
mine whether tuberculosis is confined to the conjunctiva or not. In the former 
case we would regard the operation of removing thoroughly all the diseased 
parts as of very great value, since by it the patient may be permanently relieved 
of his tuberculosis ; while in the second case a radical cure is not to be thought of. 

Ulcers op the Conjunctiva. — Ulcers of the conjunctiva, besides occurring 
as a result of tuberculosis, are also observed in the following conjunctival 
affections : 

(a) As one of the symptoms of a conjunctivitis, an example being the minute 
ulcers originating in the eflioresceuces of conjunctivitis eczematosa or those 
which have given its name to the pustular form of catarrh. 

(J) After the separation of necrotic portions of the conjunctiva, as in diph- 
theria, or after burning of the conjunctiva with heat or caustics. Here belong 
also the eschars produced artificially by the use of too strong a])plications. 

(c) As a result of exanthemata ; ulcers, for instance, which are derived from 
a variolous pustule or from the rupture of a bulla of pemphigus upon the con- 
junctiva. 

{d) Upon the tarsal conjunctiva there is quite often found a small raw spot, 
from which rises a little mass of granulations. Here we have to do with a 
chalazion which has broken through on the inner side of the lid. As a rule, a 
slender sound can be introduced through the granulations into the cavity of the 
chalazion. 

(e) I have seen in some cases on the conjunctiva of the eyeball or the plica 
semilunaris, ulcers covered with a thick layer of pus, which were of acute origin. 
These were accompanied by violent inflammatory symptoms in the conjunctiva, 
and by swelling of the lids and of the lymph gland in front of the ear, and 
were associated with quite considerable pain. It seems to me that these should 
be attributed to infection from without, produced perhaps by the stings of in- 
sects or by small infected foreign bodies. Ulcers of this kind may also be pro- 
duced by the transfer of vaccine virus from a vaccination pustule. 

(/) Ulcers which have developed from the breaking down of epitheliomata 
of the conjunctiva. 



110 DISEASES OP THE BYE. 

(g) Syphilitic ulcers. Generally we have here to do with those losses of 
substance which have arisen from the breaking down of an initial sclerosis. 
These, as a rule, are situated near the free border of the lids, but are also ob- 
served in the retrotarsal fold and even in the conjunctiva of the eyeball. The 
transmission of syphilis appears to take place most frequently by kissing, and 
in small children also by the practice which many nurses have of moistening 
the agglutinated edges of the lids with saliva in order to open them. Occa- 
sionally, also, syphilitic ulcers have been observed, which were produced by the 
breaking down of gummata of the conjunctiva (Hirschberg). Syphilitic ulcers 
of the conjunctiva are among the greatest of rarities. 



VIII. Injuries of the Conjunctiva. 

21. The following varieties of injuries of the conjunctiva, which 
are of such frequent occurrence, are observed : 

(a) Foreign bodies in the conjunctival sac. Small-sized foreign 
bodies, like grains of dust, particles of coal or of ashes, which so often 
get into the eye during a railroad journey, the wing cases of small 
beetles, etc., fall first upon the surface of the eyeball, are brushed away 
from this spot by the movements of the upper lid, and then generally 
stick to the inner surface of the latter at a spot not far from its free 
border, where a shallow furrow, the sulcus subtarsalis, runs parallel to 
the edge of the lid and catches the foreign body. The pain which such 
a foreign body causes, and which is often quite considerable, does not 
originate in the conjunctiva itself, which has very little sensitiveness, 
but in the cornea, inasmuch as with every movement of the lid the 
foreign body is carried over the cornea and scrapes it. Hence the 
pain is absent as long as the eye is kept quietly closed. It is easy to 
remove the foreign body after the lid is everted. 

In other cases, small, sharp-pointed foreign bodies penetrate into 
the conjunctiva, and may remain there a long time. Grains of pow- 
der remain fixed in the conjunctiva of the eyeball without giving rise 
to any further irritation, and may therefore be left in the conjunctiva. 
Larger-sized foreign bodies are retained in the conjunctival sac only 
when they get into the upper retrotarsal fold. In this spot they stay, 
remaining still even during the act of winking, cause no irritation of 
the cornea, and therefore produce but little trouble. After some time 
has elapsed they begin to excite the symptoms of chronic conjunctival 
catarrh. 

(b) Solutions of continuity of the conjunctiva are not rare, and 
often associated with extensive infiltration of blood (ecchymosis). If 
the edges of the wound are not too greatly lacerated, the conjunctival 
wound can be closed with a stitch. 

(c) Burns of the conjunctiva and injwies ly caustics arc pretty 
fi^equent. Burns are the result of hot water or steam, hot ashes (espe- 
cially cigar ashes), exploding powder, flames striking against the eye, 



DISEASES OF THE CONJUNCTIVA. m 

molten metal, etc. Of the injuries by caustics, which may be produced 
both by acids and by alkalies, those that arise from the action of lime 
are the most frequent, the lime getting into the eye usually under the 
form of mortar. 

The action of burns is the same as that of caustics; the conjunc- 
tiva at the affected spots is destroyed and converted into an eschar. 
These spots stand out as gray or white patches in the midst of the 
reddened and swollen portions of the conjunctiva that are not escha- 
rotic. The eschars separate in consequence of a delimiting suppu- 
ration, and the resultant granulating losses of substance in the con- 
junctiva heal by a drawing in over them of the neighboring healthy 
conjunctiva. The final result is therefore always the formation of a 
cicatrix. This can lead to a diminution in size of the conjunctival 
sac, or, if of great extent, to adhesion of the lids to the eyeball (sym- 
blepharon). 

The prognosis of an injury by burns or caustics with regard to the 
preservation of sight depends primarily upon the condition of the cor- 
nea, which, indeed, is always simultaneously affected when there is an 
extensive lesion of the conjunctiva. 

Next, although of secondary consequence, the losses of substance in 
the conjunctiva itself must be considered, inasmuch as the adhesions 
that develop from them may cause subsequently more or less disturb- 
ance of the function of the eye. 

The prime tlierapeutic requisite, when we get an eye under treat- 
ment a short time after it has been injured by caustics, is the com- 
plete removal of any corrosive substance that may still be present. We 
remove solid particles with a pledget of linen or with a forceps, and 
then wash the conjunctival sac out thoroughly. For this latter pur- 
pose we use, as far as possible, such solutions as shall neutralize the 
corrosive substance or render it insoluble, and so jDut a stop to its in- 
jurious action. In the case of caustic alkalies we do not use water, but 
milk. In burns produced by lime our best plan is to wash the eye out 
with oil and afterward to drop in a concentrated solution of sugar, 
since cane sugar forms with lime an insoluble compound. 

In the further course of an injury produced by burns or caustics, it 
is incumbent upon us to restrain the subsequent inflammation by 
means of cold compresses, atropine, the application of a bandage, etc. 
After the separation of the eschars, our aim must be to confine the 
resulting adhesions within the smallest possible limits. For this pur- 
pose we repeatedly draw the lids away from the eyeball in order to 
prevent the adhesion of the two opposite raw surfaces. If the loss of 
substance extends so far as to implicate the retrotarsal fold, an adhe- 
sion between the lid and eyeball, starting from the fornix (symbleph- 
aron posterius), can not in any way be avoided. Such an adhesion must 
be removed, as far as can be done afterward, by operative measures. 



112 DISEASES OP THE EYE. 

Sometimes foreign bodies are introduced into the eye purposely. Chief 
among those thus used are what are called crab's eyes — the lapides cancrorum. 
These are flat, calcareous concretions derived from the stomach of the crab, 
■which are in great favor among the laity as a means of removing foreign bodies 
from the eye. The crab's eye is introduced between the lid and the eyeball, 
and then is pushed across the cornea, carrying with it, it may be, mechanically 
any foreign body that chances to be there.* Sometimes it happens in the per- 
formance of this manipulation that the crab's eye slips into the superior fornix 
and remains there unnoticed. We may then find it there months or even years 
afterward, entirely imbedded in the outgrowths of the conjunctiva, which has 
undergone chronic inflammation. 

Foreign bodies, such as sand, ashes, and the like, are also intentionally in- 
troduced, for the purpose of simulating an eye disease, into the eye, where they 
set up a conjunctival catarrh. 

With regard to the presence of caterpillar's hairs in the conjunctival sac, 
see § 74 (Ophthalmia nodosa). 

After the action upon the eye of irritant substances, consisting either of 
acrid vapors or of liquids which are injected into it, an acute traumatic con- 
junctivitis is produced, evidenced by intense reddening of the conjunctiva 
with great photophobia, lachrymation, and pain, with which is associated in 
violent cases an oedematous swelling of the lids. A similar picture is presented 
by that variety of conjunctivitis which occurs after the action of intense light 
upon tlie eye, as, for example, after dazzling by the reflection from snow (snow 
blindness), or by the electric arc light (ophthalmia electrica). In violent cases 
of this sort there are found, besides the inflammation of the conjunctiva, con- 
traction of the pupil and also slight opacities and erosions of the cornea. These 
symptoms, like the erythema of the skin occurring as a result of insolation, are 
produced by the action of the ultra-violet, chemically active light rays (Wid- 
mark). These cases of traumatic conjunctivitis, in spite of the violent symp- 
toms which they present in their beginning, generally get well within a few 
days without further bad results. 

IX. Pterygium. 

22. Symptoms and Course.— A pterygium is a triangular fold of 
mucous membrane which extends from the conjunctiva of the eyeball 
to the cornea, either at the inner or the outer side of the latter (Flo-. 
30). The apex of the triangle lies in the transparent portion of the 
cornea, and is solidly and immovably united to it. The base of the 
triangle spreads out in the conjunctiva of the eyeball, and passes into 
it without there being any sharp line of division between the two. 
The apex is called the head, the base the body, of the pterygium. The 
part that lies between the two and corresponds to the margin of the 
cornea is the neck of the pterygium. Here the limits of the fold of 
conjunctiva are the most sharply defined, as its borders are rounded in 
such a way that a small sound {S, Fig. 30) can be pushed beneath them 

* [In I his country eyestones (the flat operoula of certain mollusca) are used for 
the same purpose. — D.] 



DISEASES OP THE CONJUNCTIVA. 



113 




=v^ 



^^^'n]'\'-v^ 



=^f. 



Fig. 30.— Pterygium. 

A sound, S, IS carried beneath the edge of the 
pterygium, P. The dotted line shows the 
way in which the section is made in re- 
moving the pterygium. C, caruncle. The 
adjacent plica semilunaris has been flat- 
tened out by the tensive force of the ptery- 
gium, and is hence invisible. P, upper 
punctum lacrimale. 



for a short distance. A pterygium of recent origin is succulent, and 
abounds in vessels which run converging from the base to the apex and 
impart to the pterygium its red color. In fact, from its similarity in 
form and vascularity (venation) to 
the wings of many insects (Hymen- 
optera), the name of pterygium is 
derived.* The fold of conjunctiva 
forming the pterygium is tightly 
stretched, so that there are produced 
a number of radially disposed fur- 
rows or fiutings; furthermore, in 
pterygia which are situated at the 
inner side of the eye the jDlica semi- 
lunaris is often quite obliterated 
and is included in the body of the 
pterygium (Fig. 30). 

In the course pursued by a ptery- 
gium two stages must be distin- 
guished. In the first the pter5'gium 
keeps on gradually growing, for 
years it may be, toward the center 
of the cornea, which it may finally 
reach or even pass {progressive pterygium). Finally, the pterygium 
comes to a standstill so as to remain permanently attached to the same 
point upon the cornea {stationary pterygium). Whether in any given 
case we are dealing with a progressive or a stationary pterygium is de- 
termined mainly by the character of the apex of the growth. In the 
progressive stage this appears surrounded by a gray non-vascular zone 
which looks' thick and gelatinous. In a stationary pterygium this mar- 
ginal zone is found to be thin and cicatricial looking and the whole 
pterygium is thin, pale, nearly destitute of vessels, and tendinous. 

Pterygium occurs only in that part of the cornea corresponding to 
the interpalpebral fissure. It is found most frequently on the inner 
side of the cornea ; when there is one in this spot already another may 
form on the outer side also. The two pterygia may even meet in the 
center of the cornea. A genuine pterygium is practically never ob- 
served at the upper or the lower margin of the cornea ; on the other 
hand, it is not infrequently the case that both eyes are attacked simul- 
tanepusly by pterygium, so that we sometimes see patients who have 
four pterygia, one on the outer and one on the inner side of either 
cornea. 

Among the injurious results which a pterygium entails, the worst 
is the damage done to the eyesight. This begins to be produced as 



* Prom [irrepiytov, the diminutive of] irrepv^, a wing. 



114 DISEASES OP THE EYE. 

soon as the point of the pterygium projects into the pupillary area of 
the cornea, and it increases in proportion as the point approaches the 
center of the latter. Moreover, pterygium by the tension to which it 
gives rise often causes a condition of irritation in the eye, as is shown 
by the marked injection and succulence (catarrhal inflammation) of the 
pterygium itself. In addition, the membrane, particularly if very 
much reddened, forms a striking disfigurement and can also cause a re- 
striction of the mobility of the eye. If, for example, a pterygium is 
situated on the inner side of the cornea and the eye is meant to be 
turned strongly outward, the eye may be restrained in its movement 
by the tension of the pterygium, and therefore fail to move laterally as 
far as the other or healthy eye, so that binocular diplopia may be pro- 
duced in consequence of this faulty placing. 

Etiology.— A pterygium is nothing but a fold of conjunctiva drawn 
np over the cornea and fastened to it. It originates from the Pinguec- 
ula, the degenerative process which exists there making its way into 
the limbus, and then gradually upon the cornea itself. The pinguecula, 
therefore, grows up, as it were, over the cornea, and in so doing draws 
the conj unctiva after it. Since the pterygium originates in the Pinguec- 
ula, it is evident why, like the latter, it should occur only at the inner 
and outer margins of the cornea. And as the pinguecula develops in 
consequence of the injurious influences which the conjunctiva in the 
region of the palpebral fissure is exposed to in the course of years, the 
like is true of pterygium and in a still greater degree. Hence it is 
found only in elderly people,* and in them especially when they are 
much exposed to wind or dust, as in the case of country people, coach- 
men, masons, stonecutters, etc., while among the well-to-do classes 
pterygium belongs among the rarities. The forcible traction which 
the conjunctiva exerts upon the cornea explains the triangular form of 
the fold, its incurved margin, and its great tension in a horizontal di- 
rection. 

Treatment. — The treatment of pterygium consists in its ablation by 
Arlt's method. With a toothed forceps we grasp the pterygium at its 
neck, where the incurving of its margin permits it to be partially lifted 
from its bed. Starting from this point, we carefully dissect ofi the 
head from the cornea, upon which it lies, keeping strictly to the line of 
division between the tissue of the pterygium and the cornea. We must 
be particularly cai-eful to remove thoroughly the gray, gelatinous zone 
at the apex of the pterygium, scraping or curetting the surface when 
necessary to complete the abscission. When the whole of the head as 
far as the limbus has been separated from the cornea we circumscribe 
this segment by carrying from the upper and lower margins of the neck 

[* But in this country at least is observed in comparatively young persons. 
Thus I have seen it in a boy of nineteen. — D.] 



DISEASES OP THE CONJUNCTIVA. 115 

two converging incisions into the body of the pterygium (the dotted 
line, Fig. 30). In this way a rhomboidal piece, containing the head and 
part of the body, is excised and a raw surface remains, one portion of 
which lies in the cornea, the other in the conjunctiva of the eyeball. 
This last is covered by uniting the upper and lower margins of the sec- 
tion by means of one or two interrupted sutures. The wound in the 
cornea heals by a cicatrix forming over it, in consequence of which a 
permanent opacity remains. Care in sewing up the conjunctival wound 
is of the greatest importance, especially in the neighborhood of the 
limbus, as otherwise the conjunctiva grows anew over the raw surface 
of the cornea, and thus the pterygium recurs. However, even after 
carefully performed operations relapses are not infrequent, and then a 
second removal is required. 

Ablation is indicated in every case of progressive pterygium. Even 
though the pterygium is still small, we can not be sure that it will not 
grow on into the pupillary area of the cornea. Hence we prefer by per- 
forming ablation to guard in time against injury to the eyesight. If 
the pterygium has approached sufficiently near the center of the cornea 
to cause disturbance of vision, this disturbance is indeed rendered less 
by the operation of ablation, but is not completely done away with, 
since those spots of the cornea, which were occupied by the pterygium, 
never again become perfectly transparent. In any case, the associated 
symptoms of irritation, the restriction of mobility, and the disfigure- 
ment are removed by the ablation. A stationary pterygium does not 
necessarily require ablation ; in this case we shall be guided mainly by 
the wishes of the patient with reference to the removal of the disfig- 
urement, etc. 

The older writers distinguished a pterygium crassum (vasculosum, carno- 
sum, sarcomatosum) and a pterygium tenue (membranaceum). Tlie former cor- 
responds to a catarrhally inflamed, and hence'therefore red and thick pterygium, 
the latter to a stationary pterygium, which has become thin and tendinous. 

A pterygium has been shown to be histologically identical with the conjunc- 
tiva of the eyeball, of which indeed it is only a drawn-out and projecting fold. 
It consists mainly of fibrillar connective tissue, which is covered with the epi- 
thelium of the conjunctiva. The apex of the pterygium, however, is often 
covered by the corneal epithelium, so that the pterygmm may be said to force 
its way underneath the latter. In the tissue of the pterygium are found new- 
formed tubular glands and also larger spaces lined with epithelium ; from both 
of these small cysts may develop. Bowman's membrane, where it lies beneath 
the pterygium, is destroyed ; indeed, the uppermost lamellae of the cornea even 
are replaced here and there by the tissue of the pterygium. This explains why, 
even after the ablation of the pterygium, the cornea does not regain its normal 
transparency. 

Arlt deserves the credit of having made the operation for pterygium a suc- 
cess by demonstrating the necessity of closing the conjunctival wound. Pre- 
viously people had been satisfied with simple ablation, and had so frequently 



116 DISEASES OF THE EYE. 

had recurrences after this operation that with many it had altogether fallen 
into disrepute. In very broad pterygia it is difficult or impossible to unite the 
edges of the conjunctival wound by a suture. In that case liberating incisions 
are made through the adjacent conjunctiva in order to facilitate the process of 
drawing it down ; and, instead of cutting oflE the point of the pterygium, it 
may be sewed into the gaps which have been made by the liberating incisions. 
PsBUDO-PTEETGiUM (CICATRICIAL Ptekygitjm). — Sometimes we observe as 
a result of inflammatory processes fixation of a fold of conjunctiva upon the 
cornea, giving a picture similar to that of true pterygium. For example, there 
may be an acute blennorrhoea of the conjunctiva, with great chemosis, and 
a pretty large marginal ulcer of the cornea. The chemotic protuberance of the 
conjunctiva becomes applied to the surface of the ulcer and adheres to it. After 
the inflammation has abated, the swelling of the conjunctiva goes down, the 
chemotic protuberance disappears; but, in the spot where union of the cornea 
has taken place, the conjunctiva remains permanently fixed to the latter. We 
then see a triangular fold formed of conjunctiva extending over the limbus 
and upon the cornea, and attaching itself there. Ordinarily, at that part of the 
fold corresponding to the limbus a fine sound can be passed all the way beneath 
the fold, a sign that the latter is adherent to its bed at its apex only and not 
throughout its whole extent. This is the most important distinguishing mark 
between a true and a false pterygium ; another consists in the fact that a pseudo- 
pterygium does not keej) on growing over the cornea, as a true pterygium does, 
but remains steadily fixed to the spot at which it first became adherent. In its 
origin and its behavior a pseudo-pterygium is more like a symblepharon than 
a genuine pterygium. 

Pseudo-pterygia are observed not only after acute blennorrhoea, but also 
after diphtheria, burning by heat and by caustics, prolapses of the iris, the re- 
moval of new growths, etc. It is evident that they may develop not only at 
the outer and inner sides, but at any side whatever of the cornea. The pseudo- 
pterygia remaining after acute blennorrhoea are usually found above, those pro- 
duced by burns, etc., most frequently at the lower part of the cornea (the re- 
gion corresponding to the palpebral fissure). 

Another kind of pseudo-pterygium is that which develops after a chronic 
superficial ulceration of the marginal portions of the cornea (keratitis margina- 
lis superficialis, Fig. 51). Owing to the cicatrization which follows the ulcera- 
tive process the conjunctiva is steadily drawn up over the cornea. These 
pseudo-pterygia are very similar to true pterygia, for like the latter they keep 
on growing slowly over the cornea, and unlike other pseudo-pterygia are not 
completely perforate at the limbus. The differential diagnosis between these 
and the true pterygia can be made only in case we find the ulcerative process 
or its sequelae (a superficial corneal opacity) upon the marginal portions of the 
cornea not implicated in the pterygium. 

Small pseudo-pterygia may without disadvantage be left undisturbed- 
larger ones we generally remove in the same way as genuine pterygia and unite 
with stitches the wounds left in the conjunctiva. In those cases in which the 
pseudo-pterygium is not adherent to the surface of the eyeball at the spot cor- 
responding to the limbus, ablation and the use of the suture may be dispensed 
with ; it is sufiicient simply to free the point of the pseudo-pterygium from the 
cornea, upon doing which the former retracts of itself and disappears by a 
process of atrophy. 



DISEASES OP THE CONJUNCTIVA. 117 

It sometimes happens that an old pannus which has already been trans- 
formed into connective tissue is united to the subjacent cornea only by loose 
cellular tissue, and thus acquires a certain freedom of movement, so that it can 
be shifted this way and that upon its bed along with the conjunctiva of the 
eyeball. In this way too, then, a picture similar to that of a pterygium may 
be produced. 

X. Stmblephaeon. 

23. Symptoms. — By symblepharon * we understand a cicatricial 
adhesion between the conjunctiva of the lids and the conjunctiva of 
the eyeball. In that case, when we attempt to draw the lid away from 
the eyeball, we observe that in one or more places bands extend from 
the inner surface of the lid to the surface of the eyeball, and that these 
become tightly stretched and prevent us from drawing the lid away 
completely. These bands generally look tendinous, more rarely fleshy, 
and may be attached not only to the conjunctiva sclerse, but also to 
the surface of the cornea itself. If the adhesion between the two con- 
junctival surfaces extends so far peripherally as to reach into the fornix, 
we call this symUeplmron posterius (Fig. 31 B). If the adhesion does 






Fig. 31.— Symblepharon (Schematic). 

A, symblepharon anterius; B, symblepharon posterius by adhesion; C, symblepharon posterius 
by cicatricial shrinking ; /, fornix. 

not extend as far as this, so that the cicatricial bands stretch like a 
bridge between the lid and the eyeball, and we can introduce a sound 
beneath them and carry it along the fornix between the lid and the 
globe, it is then called symllepharon anterius (Fig. 31 A). This 
distinction has been established for practical reasons, inasmuch as 
symblepharon anterius can be readily cured by an operation, while 
symblepharon posterius can be cured with difficulty or not at all. 
SymilepTiaron totale is a total adhesion between the lids and the eye- 
ball — a condition which occurs but rarely. 

Etiology. — Symblepharon develops whenever two opposed spots of 
the conjunctiva of the lid and of the eyeball have raw surfaces which 

* Prom aiv, together, and fi\e(papoy, eyelid. 



118 DISEASES OF THE EYE. 

come into contact with each other, and in consequence become adher- 
ent. Such a process of adhesion results of necessity when the two 
raw surfaces extend up into the fornix and there pass into each other, 
since two raw surfaces which meet at an acute angle always begin to 
unite at this angle of junction. Causes which can give rise to the 
formation of raw surfaces ujDon the conjunctiva are burns by the action 
of heat, burns from caustic substances, diphtheria, operations, ulcers of 
all kinds, etc. 

The expression symblepharon is also employed in a somewhat dif- 
ferent sense to denote the contraction of the conjunctiva which occurs 
as a result of its gradual shrinking^ as, for instance, after trachoma (see 
page 71). In this case it is not a question of an adhesion between two 
raw conjunctival surfaces, but of a gradual diminution in size of the 
conjunctival sac. The folds of the region of transition are first 
smoothed out ; the conjunctiva of the lid extends directly to the eye- 
ball (Fig. 31 C), and whenever the lid is drawn away is made tense 
and drawn out into transversely disposed folds. In advanced cases the 
conjunctival sac is converted into quite a shallow groove between the 
eyeball and the lid. Since contraction of the conjunctival surface in 
consequence of shrinking always makes itself first apparent by disap- 
pearance of the retrotarsal fold, all these cases belong to symbleph- 
aron posterius. This kind of symblepharon is observed principally 
after trachoma ; furthermore, in the rare cases of pemphigus of the 
conjunctiva. 

Very light cases of symblepharon produce no bad results worth 
mentioning. When there are more pronounced adhesions, the excur- 
sions of the eye are hindered, and thus possibly diplopia may be pro- 
duced just as in the case of pterygium. Inasmuch as with the move- 
ments of the eye traction is made at the site of the adhesions, the eye 
gets to be in an irritated condition. If the adhesions extend into the 
region of the palpebral fissure they become disfiguring, and if they 
extend as far as the cornea they may injuriously affect the sight. 
Sometimes the lids are so fastened down by extensive adhesions that 
their complete closure is impossible, and lagophthalmus is produced 
with its consequences that are so baneful to the cornea. Total sym- 
blepharon is obviously associated with complete blindness (or at most 
with quantitative perception of light). 

Treatment.— This involves an operation. Cases of symllepliaron 
anterius are easily cured. "We separate the adhesions between the lid 
and eyeball with great care, so as not to cut into the sclera or the 
tarsus. When the lid has been set free, we must then make it our 
business to prevent a readhesion of the freshly made raw surfaces, and 
to make each of these cicatrize by itself. This is effected by repeatedly 
drawing the lid away from the eyeball, and also by interposing a pledget 
dipped in oil or smeared with ointment between the lid and the eye. 



DISEASES OF THE CONJUNCTIVA. 



119 



:{^^.4hl^ 



111 symblepliaron posteriiis we also begin by separating the adhe- 
sions as far back as tlie fornix. "We tlien see, when we have drawn the 
lid away from the eyeball, two corresponding 
raw surfaces, one in the eyeball, the other on 
the lid (Fig. 32). These two opposed sur- 
faces, which meet at the fornix, would soon 
reunite, beginning at the fornix, if we did 
not take care to have one of the raw surfaces 
covered with conjunctiva, so that a place 
coated with epithelium lies opposite to the 
raw surface remaining. The wound on the 
eyeball is the one we select for covering over, 
because the conjunctiva of the eyeball can 
readily be displaced, while the conjunctiva 
of the lid is adherent immovably to the tar- 
sus. We loosen the conjunctiva of the eye- 
ball on both sides of the wound, draw it 
down over the latter, and unite it by sutures. 
Especial care must be devoted to uniting the 
wound in the neighborhood of the fornix. 
If, after dividing the adhesions, the raw sur- 
face upon the eyeball is so large that it can 
not possibly be covered by conjunctiva, re- 
union of the symblepharcn will inevitably 

result. Hence, cases of extensive symblepharon posterius, and obviously 
also cases of symblepharon totale, are incurable. The same is true of 
symblepharon induced by the gradual shrinking of the conjunctiva. 




Fig. 32. — Operation for a Sym- 
blepharon Posterius. 

The wound in the palpebral con- 
junctiva (a) has been left open, 
that in the bulbar conjunctiva 
closed by two interrupted su- 
tures. In order to be able to 
draw the conjunctiva up over 
the raw surface, a liberating 
incision has been made along 
the margin of the cornea, in- 
ward and outward from the 
upper end of the wound. 



We sometimes also operate for symblepharon in the case of a blind and shriv- 
eled eye so as to be able to introduce an artificial eye over it. 

Different methods have been devised to enable us to operate for cases of 
symblepharon posterius with extensive adhesion. Himly, in an operation analo- 
gous to that for syndactylism, first made a preliminary perforation of the adhe- 
sion along the fornix, and carried a lead wire through the canal so formed. 
The latter, after the wire has been in it a pretty long time, becomes covered 
with epithelium (like the canal made by piercing the lobule of the ear for ear- 
rings), so that the symblepharon posterius is changed into a symblepharon an- 
terius, and can be operated upon, like the latter, by simply separating the adhe- 
sion. Some have attempted to cover a large loss of substance upon the eyeball, 
caused by the removal of a symblepharon, by making the conjunctiva that is to 
be drawn up over it movable by means of liberating incisions, or by fashioning 
pedicellate flaps out of conjunctiva and attaching them to the wound (Teale, 
Knapp). Others (Stellwag, Wolfe) have grafted nonpedicellate flaps formed 
out of bits of mucous membrane from other localities (the conjunctiva of the 
other eye, the mucous membrane of the lips, or that from the mouth or vagina, 
or even the mucous membrane of animals) upon the raw spot, and have obtained 
union. Others again, for covering a loss of substance, take the external skin 



120 DISEASES OF THE BYE. 

either in the form of small flaps grafted upon the surface, or as pedicellate 
flaps which are thrust in between the eyeball andy the lid through a fenestra 
cut through the latter (Kuhnt, Snellen). Generally speaking, we are obliged to 
acknowledge that in extensive adhesions all methods have but scanty results to 
offer, since the symblepharon commonly returns on account of the subsequent 
shrinking of the conjunctiva. 



XI. Xerosis. 

24. Symptoms. — Under the name of xerosis * conjunctivae we desig- 
nate an alteration of the conjunctiva, the essential character of which 
is that the latter is dry. The surface of the conjunctiva at the xerotic 
spots shines like fat and is of a whitish color, and looks either like epi- 
dermis or as if it were covered with dried foam. In such places the 
conjunctiva is thicker, less pliable, and lies in stiff folds. The tears 
flow over the diseased spots without moistening th'em. An analogous 
change is also observed in the cornea, the surface of which looks dull, 
lusterless, and dry, while the parenchyma of the cornea at the same 
time is found to have lost its transparencj' (xerosis cornese). 

Etiology. — The cases in which xerosis is observed are divided into 
two groups. In the first, xerosis is the result of a local affection of the 
eye ; in the second, it is an accompanying symj)tom of a general disease. 

Xerosis resulting from a local affection of the eye is found : 

(a) In cicatricial degeneration of the conjunctiva. It is observed 
most frequently as the final outcome of trachoma, and also, but more 
rarely, after dijihtheria, pemphigus, burns, etc. It begins in isolated 
spots, but may ultimately spread over the entire conjunctiva, and over 
the cornea also. In the latter case, since the xerotic cornea grows 
opaque, the eye becomes blind. This form of xerosis is incurable. 

{fi) Deficient sheltering of the conjunctiva, so that the latter is con- 
stantly in contact with the air, can likewise lead to xerosis. This 
occurs in ectropion and in lagophthalmus (incomplete closure of the 
lids). In the former case the exposed portion of the tarsal conjunctiva, 
in the second case that part of the scleral conjunctiva and of the cor- 
nea lying in the course of the palpebral fissure, becomes covered with 
a thickened, dry, epidermoid epithelium, by means of which these parts 
protect, so to speak, their deeper layers against desiccation. In such 
cases assistance can be rendered only when it is possible (by operative 
interference) to provide the exposed conjunctiva or cornea with its 
normal shelter again. 

Xerosis, resulting from a general disease, occurs under a light and a 
severe form : 

(a) The light form is associated with hemeralopia (night blindness). 
Simultaneously with the peculiar disturbance of vision (see § 104) there 



* From ir,p6s, dry. 



DISEASES OF THE CONJUNCTIVA. 



121 



are found on the outer and inner side of the conjunctiva bulbi small 
triangular spots, which are covered with what resembles fine dried 
foam, and which are not moistened by the tears (Bitot). This form of 
the disease attacks adults. 

(b) The severe form is associated with keratomalacia (see § 38). 
Here also xerosis makes its appearance first in the region of the con- 
junctiva corresponding to the palpebral fissure, but subsequently it 
spreads to the cornea, which breaks down into pus. The disease attacks 
children only, who often die with the symptoms of a severe general 
disease. It is conjectured that the light and the severe form are but 
different grades of one and the same disease, the essential nature of 
which is still unknown to us. The xerosis, which in these cases attacks 
a hitherto perfectly healthy conjunctiva and cornea, must be looked 
upon as a consequence of the disturbance of nutrition produced by the 
disease. Its particular importance to us, therefore, is as a symptom of 
this general affection, against which, accordingly, treatment must be 
particularly directed. 

The separation, first made by Cohn, of xerosis into a variety dependent upon 
local causes and one caused by a general disease corresponds nearly to the 
ordinary division into xerosis parenchymatosa and 
xerosis epithelialis. In local xerosis the mucous 
membrane is diseased in its deeper as well as in the 
superficial layers (xerosis parenchymatosa); while 
in xerosis produced by a general disturbance of nu- 
trition the change affects the epithelium only (xero- 
sis epithelialis). Many also make a distinction be- 
tween xerosis partialis (sive glabra) and xerosis 
totalis (sive squamosa). Fia. 33.— Xerosis Conjukc- 

The anatomical changes which form the basis ^'^^ Magnified 820 x l. 
of xerosis principally affect the epithelium. The ^P'j;?^{i?'eon]uTo?fvl'l?a'J^^^^^ 
uppermost layers of eT)ithelial cells undergo kera- affected with keratomalacia. 
, . ,, , , \. ,, T. , Colored by Gram's method, 

tosis, the protoplasm of the succeedmg layers con- The nucleus of the cell is 

taining abundant granules of keratohyalin (Fig. 33). ^!g^^^ ZmJr'^ustln- 

In consequence the epithelium appears thickened, "'«« "f keratohyalin lymg m 

. ^ '^ ^ ^ . .' the protoplasm of the cell. 

whitish, cloudy, and epidermoid. Moreover, it is Upon the cell are seen xero- 

covered with the sebumlike secretion of the Meibo- fn^size! 'The'iarger-'siledba^ 

mian glands, and hence assumes a fatty character, "^i"' ''f^.,''"**'°SV^\ biscuit- 
° ' J J shaped ; the smallest ones re- 

in consequence of which the laclirymal fluid does semble oblong cocci. 

not adhere to it. To this circumstance the peculiar 

dry appearance is chiefly owing, for if the diseased spots are freed from their 

fat by the application of soap they become capable of being wetted by the tears 

(Leber). 

Reymond and Colomiatti and shortly afterward Kuschbert and Neisser de- 
scribed as occurring in xerosis a special micro-organism, the bacillus of xerosis, 
which is extremely like the diphtheria bacillus. This is found under the form 
of short rods adhering in great quantities to the surface of the epithelial cells. 
It is, however, neither the cause of xerosis, nor indeed characteristic of the 
latter. It occurs frequently in the conjunctival sac at all times, and simply 




122 DISEASES OF THE BYE. 

seems to find in the dying epithelium of the xerotic spots a specially favorable 
soil for growth, so that it develops there in great quantities (Fig. 33.) In any 
ca^e, it can not be the special exciting cause of the disease; on the contrary, we 
must assume that coming from the air it gets upon the conjunctiva, and finds in 
the epithelium of the latter a soil favorable for its growth, whenever this epi- 
thelium has had its nutrition injuriously affected. 

What part does the lachrymal secretion play in xerosis ? The real cause of 
the dryness of the conjunctiva is not, as has been believed, the deficiency of 
tears. In the beginning of the disease, as long as only small isolated spots of 
the conjunctiva are xerotic, we often find actually an increase in the lachrymal 
secretion. Per contra, xerosis of the conjunctiva has never been known to 
occur after extirpation of the lachrymal gland. The real cause of the dryness 
of the conjunctiva is rather the fact that the tears do not adhere to it. Never- 
theless it is true that in advanced xerosis the lachrymal secretion diminishes, 
and may even disappear altogether, for, owing to the marked shrinking of the 
conjunctiva, the excretory ducts of the lachrymal gland, which empty in the 
upper retrotarsal fold, are closed, and as a result of this, atrophy of the gland 
itself ensues. The patients, when led to weep by their melancholy state, feel 
only a sensation of fullness in the eyes ; the tears do not come. Arlt found in 
a case of xerosis obliteration of the efferent ducts of the lachrymal gland pro- 
duced by the great shrinking of the conjunctiva, the lachrymal gland itself 
being diminished to one third of its normal volume and transformed into a 
tissue resembling fat. In that form of xerosis also which occurs in connection 
with keratomalacia there is a striking deficiency in the lachrymal secretion ; but 
here probably we have to do with a nervous disturbance, namely, with an ab- 
sence of the reflex lachrymal secretion, due to depression of the general nu- 
trition, and particularly of the nervous functions. In a case of this sort Cirin- 
cione has found on autopsy an inflammation of the ciliary ganglion and ganglion 
Gasseri. 



XII. Extravasation of Serum and Blood beneath the 
Conjunctiva. 

25. OEdema and also extravasation of blood, if of any great extent, 
are observed only in the conjunctiva of the eyeball and in the retro- 
tarsal fold, as these, on account of the laxity with which they are fixed 
to the subjacent parts, can be readily lifted up over quite large areas 
by fluid. The same thing does not occur in the conjunctiva tarsi, be- 
cause it is too intimately adherent to the underlying cartilage. 

In the conjunctiva of the eyeball we meet with both inflammatory 
(Bdema (cedema calidum), occurring in inflammations of the eyeball or 
the organs near it, and with non-inflammatory redema (cedema frigi- 
dum), resulting from simple transudation of fluid. Since cedema, as a 
rule, is of importance merely as a symptom of some other affection, 
treatment will have to be directed to the latter. Should it be desirable 
to take any special measures against the cedema itself, the most suita- 
ble means for this purpose would be a pressure bandage, or, in the case 
of a tense oedema, scarification of the conjunctiva. 



DISEASES OF THE CONJUNCTIVA. 123 

The exudation of blood beneath the conjunctiva of the eyeball is 
known as eccliymoma subco7ijunctivale. We then see a spot of varying 
extent and of a vivid-red or dark-red color ; sometimes the whole con- 
junctiva scleras is suffused with blood. Ecchymosis is easily distin- 
guished from an inflammatory redness of the conjunctiva by its uni- 
formly red coloration, in which no network of vessels can be recognized, 
and also by its sharp limitation from the unsuffused portions of the 
conjunctiva, which are ordinarily quite normal and uncolored. 

Ecchymoses of the conjunctiva develop after injuries and operations 
upon the conjunctiva (particularly after squint operations), and, fur- 
thermore, in violent inflanp^mations, especially in catarrhal ophthalmia. 
Spontaneous suffusions in an otherwise healthy conjunctiva are fre- 
quent in old people, whose blood-vessels have brittle walls, the rup- 
ture of the vessels being often occasioned by great bodily exertion, or 
by coughing, sneezing, vomiting, great straining, etc. In children 
also spontaneous ecchymoses of the conjunctiva are observed, chiefly 
after whooping-cough. A special symptomatic significance belongs to 
those ecchymoses which develop, to all appearance spontaneously, after 
an injury to the skull. Here we have to do with cases in which a 
fracture of the base of the skull has occurred, and the blood, as it 
escapes, gradually oozes forward through the orbit until it lodges 
beneath the conjunctiva (see § 133). 

Subconjunctival ecchymoses become absorbed in from a few days to 
a few weeks without producing any further serious consequences, and 
in themselves require no treatment whatever. We generally prescribe 
compresses of lead water, more for the purpose of appeasing the patient 
than of obtaining a more speedy resorption. 

Inflammatwy mdema is associated with the most various inflammatory affec- 
tions, such as inflammations of the lids (erysipelas, hordeolum), of the margin 
of the orbit (periostitis), of the lachrymal sac (dacryocystitis), of the conjunc- 
tiva (particularly acute blennorrhoea), of the eyeball itself (purulent keratitis, 
irido-cyclitis, purulent chorioiditis, and panophthalmitis), and, furthermore, of 
structures posterior to the eyeball (tenonitis, phlegmon of the orbit). Inflam- 
matory oedema, as also exudations of serum or of blood, is especially apt to 
occur in old people, whose conjunctiva is eminently extensible and so loosely 
attached that we observe oedema in this situation sometimes with trifling con- 
junctival catarrhs. We commonly find the oedema most pronounced in the 
region of the palpebral fissure, because here the counter-pressure exerted by the 
lids is wanting; and not infrequently an oedematous fold of conjunctiva is found 
in the palpebral fissure, pinched off, so to speak, from the rest by the lids. 

Non-mflammatory adema is caused by hydrsemia or by stasis. In the former 
case it occurs as a symptom of albuminuria, and sometimes then recurs a num- 
ber of times, but each time rapidly disappears again (oedema fugax). A pe- 
culiar sort of cedema is the filtration cedema of the conjunctiva of the eyeball. 
It is observed after operations or injuries which have produced a perforation in 
the most anterior sections of the sclera, and arises from the fact that the aqueous 



124 DISEASES OF THE EYE. 

from the anterior chamber oozes between the incompletely closed edges of the 
wound and lodges under the conjunctiva. Accordingly, when cicatrization oc- 
curs, the oedema commonly disappears. But if a minute opening remains in 
the sclera, the cedema too persists — a condition w^hich is designated as cystoid 
cicatrization (see Fig. 65). CEdema from filtration is found either in the region 
of the fistulous opening or in the lower part of the bulbar conjunctiva, the fluid 
sinking in obedience to gravity. 

Not infrequently we see in the scleral conjunctiva small bright vesicles, 
arranged in a row like a string of pearls, or even joined so as to form longer 
sausage-like swellings. Here we have to do with dilated lymph vessels that are 
filled with a clear liquid — that is, with lympliatic ectasice. These occur both in 
inflammation of the conjunctiva and also when the conjunctiva is perfectly 
healthy. 

Mcchymoses of the conjunctiva, free from danger as they are, terrify the 
patient by their conspicuous look, especially if, as is frequently the case, they 
spread still further in the next few days after their first development. In 
these cases the Pinguecula stands out with peculiar distinctness, as a bright, 
white, or yellowish spot upon the red substratum. On the side of the trans- 
parent cornea the ecchymosis is limited by a narrow gray border. This is the 
inner margin of the limbus, which is too closely adherent to the cornea to be 
lifted up by the blood. In eyes with blue iris, the latter often has its color 
apparently changed to green in the spot corresponding to the ecchymosis. This 
is caused by the extension of the blood in a very thin layer (in which it appears 
green) between the lamellse of the cornea, so as to make the iris which lies be- 
hind it seem green. 

The entrance of air beneath the conjunctiva of the eyeball (emphysema) is 
sometimes observed simultaneously with the escape of air beneath the skin of 
the lids or into the orbital tissue (see § 114). 

XIII. TUMOES OF THE CONJUNCTIVA. 

26. Both malignant and benign tumors occur in the conjunctiva. 
The most important form of benign tumors is the 

Dermoid Tumor.— This is a flat growth of solid consistence, which, 
so to speak, straddles the margin of the cornea, being situated partly 
in the conjunctiva, and partly in the cornea, with which latter it is 
immovably connected. It most frequently occurs on the external (tem- 
poral) side of the cornea (Fig. 34). Its color is white or reddish, its 
surface epidermoid and often dry. It is sometimes covered with fine 
down, or even with longer hair. Histological examination shows that 
the growth possesses the composition of the external skin ; it consists 
of a stroma of connective tissue, covered with epidermis, and contains 
hair follicles, sebaceous glands, and sweat glands. It is, so to speak, an 
island of skin upon the surface of the eyeball. 

Dermoid tumors are always congenital, and are frequently found 
along with other congenital anomalies, like congenital harelip or wart- 
like appendages of skin in front of the ears. Sometimes they grow 
still larger after birth. According to Eemak, their development, as in 



DISEASES OP THE CONJUNCTIVA. 



125 




the case of the allied dermoid cysts (see § 134), depends upon a foetal 
invagination of the external germ layer. On the other hand, Von 
Duyse conjectures that they owe their origin to a circumscribed ad- 
hesion between the amnion and the sur- 
face of the eyeball. The adhesion sub- 
sequently is drawn out into the form of a 
cord, and at length breaks quite in two, 
its point of attachment to the eye remain- 
ing behind as a dermoid tumor. 

The chief harm that dermoids do is 
to produce a considerable disfigurement. 
If they are large, and especially if they 
are covered with hair, they cause me- 
chanically an irritation of the eye, and 
also interfere with vision, in so far as tliey 
encroach upon the pupillary area of the 
cornea. They are removed by a simple 
process of ablation, which consists in 
separating the tumor as exactly as pos- 
sible from the subjacent cornea and 
sclera. The resulting wound in the cor- 
nea should, as far as possible, be covered 
by drawing the adjacent conjunctiva over 
it. That portion of the cornea upon 
which the tumor was formerly situated 
remains clouded permanently. If rem- 
nants of the tumor have been left, the 
latter may in part form again. 

Of malignant tumors, epithelioma and 
sarcoma of the conjunctiva occur. These 
originate ordinarily in the limbus conjunctiva, and thence extend both 
into the conjunctiva and into the cornea. 

Epithelioma of the conjunctiva forms a non-pigmented, flat, sessile 
tumor with a broad base. It remains for a long time confined to the 
superficial layers of the conjunctiva and cornea, its extension in the 
latter often resembling a pannus. The tumor shows a great tendency 
to superficial ulceration. 

The sarcomata that start from the limbus are generally pigmented 
(melano-sarcomata). In opposition to an epithelioma, they grow more 
in height than in breadth, and are attached to the substratum by only 
a slender base. They hence form dark-colored, very prominent mush- 
roomlike growths, which often overlie a great part of the cornea, 
although, if we lift them up, we find the cornea beneath for the most 
part normal. 

Both epitheliomata and sarcomata develop in advanced life, and, 



Fig. 34.— Dermoid Tumor of the Cor- 
nea AND Subconjunctival Lipoma 
IN A Thiktekn-year-old Girl. 

The dermoid tumor is situated on the 
outer and lower margin of the cor- 
nea, lying to a small extent in the 
cornea, and more largely in the 
sclera. The eye has to be turned 
strongly inward in oi'der to bj-ing 
the lipoma well into view. The lipo- 
ma has a form differing from the 
ordinary one in that it consists of 
two lobules, and in addition sends 
out a process reaching to the outer 
margin of the cornea. It is every- 
where covered by compact con- 
junctiva which resembles skin, but 
which nevertheless allows the yel- 
low color of the underlying fat to 
show through. 



126 DISEASES OP THE EYE. 

if they are not removed, spread steadily ; sarcomata especially grow, 
until at length they form gigantic tumors. At last the patient suc- 
cumbs from exhaustion, or from metastases which form in the internal 
organs. The tumors must therefore be removed as early and as radically 
as possible. As long as they are still quite small and superficial radical 
removal can be performed with preservation of the eyeball. The tumor 
is removed as completely as possible, partly with the knife, partly with 
the sharp spoon, and the spot which it has occupied is thoroughly 
burnt with caustics, or, still better, with the actual cautery. If com- 
plete removal of the growth is no longer possible in this way, the eye, 
too, must be removed, even though it still possesses visual power. 

Of benign growths, the following, although of rare occurrence, are also ob- 
served : 

Lipoma subconjunctliiale forms a tumor, situated upon the upper and outer 
circumference of the eyeball, between the rectus externus and rectus superior 
muscle, and appearing of a yellowish color as seen through the conjunctiva. It 
is of triangular form, the sharply defined base of the triangle looking toward the 
cornea, while the two sides of the triangle, which are directed to the outer side, 
pass gradually into the orbital fat. If the tumor is small it ordinarily remains 
concealed beneath the outer canthus, and can be brought into view only by 
turning the eye strongly inward (Pig. 34). Larger lipomata are visible in the 
palpebral fissure even when the gaze is directed straight forward, and hence 
cause disfigurement; but they do no other harm. Microscopical examination 
shows that the tumor consists of fat lobules. The conjunctiva that coats it is 
thickened and of a character resembling skin, and in this regard a lipoma is 
akin to the dermoids (lipo-dermoid). Like the latter, it is congenital, but 
sometimes grows to a considerable size at the time of puberty. If it is desired 
to remove the tumor on account of the disfigurement it produces, we take away 
from it, after dividing the conjunctiva that covers it, as much of the mass of fat 
as is visible in the palpebral fissure ; a radical removal of all the adipose tissue 
is unnecessary. 

Cj/sts in the conjunctiva are commonly represented by small vesicles filled 
with a limpid liquid. Most of these vesicles, and particularly those situated 
upon the conjunctiva of the eyeball, originate from dilated lymph vessels (see 
page 134). In the retrotarsal fold cysts occur which take their starting point 
from Krause's glands, or from new-formed glands in the conjunctiva (page 43) ; 
and there are also cysts that are produced in the conjunctiva by traumatism. 
Larger cysts situated beneath the conjunctiva are formed by the cysticercus 
cellulosae. The latter is observed for the most part in children or in the young. 
In such a case the conjunctiva at one particular spot is found permeated with 
vessels, and forms a nodular protuberance. Underneath may be felt the cyst 
which, as a rule, can be readily pushed about upon the subjacent parts ; in indi- 
vidual cases, however, it is intimately adherent to the subjacent sclera or to one 
of the ocular muscles. If the cyst has very thin walls, the head of the worm can 
be recognized as a whitish spot in its interior. It is easy to remove the cysti- 
cercus by splitting up the conjunctiva and dissecting out the cyst, which con- 
sists of the cysticercus vesicle inclosed in a capsule of connective tissue that has 
been formed about the animal. 



DISEASES OP THE CONJUNCTIVA. 127 

Under the name of polypi of the conjunctiva we understand soft, rarely 
rather hard, outgrowths attached to the conjunctiva by a pedicle, and having a 
smooth surface covered with mucous membrane. These originate most fre- 
quently in the retrotarsal fold or in the conjunctiva of the lids. As a rule, they 
are so small as not to be disclosed until the lids are everted ; sometimes, how- 
ever, they are large enough to project out between the lids. Larger polypi are 
frequently ulcerated upon their surface, as a result of the mechanical injuries 
to which they are necessarily subjected. In their nature polypi are small fibro- 
mata, which thrust the conjunctiva like a sac before them. Their treatment 
consists in ablation and a subsequent cauterization of their base with the silver- 
nitrate stick. 

Papillomata of the conjunctiva are frequently confounded with polypi, but 
are distinguished from them by their surface being not smooth, but papillary — 
that is, nodulated, like a raspberry or cauliflower. They are either provided 
with a pedicle or are sessile, having a broad base and extending in a flat layer 
over quite a large section of the conjunctiva. They start most frequently from 
the region of the caruncle, but can also take their origin from other portions of 
the conjunctiva, and sometimes several papillomata at once are present in dif- 
ferent portions of the conjunctiva. They must be removed very thoroughly, 
since they are extremely prone to recur. 

A third form of tumor, having an external resemblance to polypi of the 
conjunctiva, are the granulation tumors. These, like polypi, form small, mush- 
roomlike, pedicled tumors. Unlike polypi, however, they are not covered by 
conjunctiva, but consist of naked granulation tissue. They develop in places 
where a loss of substance exists in the conjunctiva, wliether as a result of ulcers 
(or even large efilorescences in cases of conjunctivitis eczematosa) or as a result 
of injuries or of operations (most frequently after tenotomies, at the site of the 
conjunctival wound, and, after enucleation, at the bottom of the conjunctival 
sac). In the case of chalazia, also, which have broken through the conjunctiva 
of the lids, we quite often see a granulation mass growing out of the opening. 
After existing for some time granulation tumors become more and more con- 
stricted at their base by the cicatricial contraction of the surrounding conjunc- 
tiva, so yaat they ultimately fall oS of themselves if they have not been previ- 
ously removed. 

The three varieties of tumors above mentioned often contain an abundance 
of dilated vessels; in fact, some cases of very vascular polypi have been de- 
scribed as pediculated angiomata of the conjunctiva. It is hence easy to con- 
ceive how these tumors can readily give rise to repeated hfemorrhages, especially 
if they are ulcerated in spots and are mechanically injured, as, for example, by 
the rubbing of the lids upon them. Many legends of tears of blood may be 
referred to this cause. 

Angiomata of the conjunctiva are, as a rule, those which were originally 
situated in the lids and have gradually passed over upon the conjunctiva. Pri- 
mary angiomata are of rare occurrence in the conjunctiva, and are generally 
found in the region of the inner angle of the eye. They are as a rule congenital, 
and increase in size after birth. With regard to their treatment, see Angiomata 
of the Lids (§ 115). 

As regards the malignant tumors, the epitheliomata and sarcomata, we must 
distinguish between those which originate in the surrounding structures, espe- 
cially the lids, and secondarily pass over upon the conjunctiva, and those which 



128 DISEASES OP THE EYE. 

are from the beginning situated upon the conjunctiva and are hence to be 
looked upon as primary conjunctival tumors. These latter originate mostly 
from the limbus. The predilection shown by epitheliomata for the boundary 
line between the conjunctiva and cornea is to be considered as an analogue of 
the fact that, in other parts of the body also, epitheliomata occupy by prefer- 
ence those spots where one kind of epithelium passes into another, as, for 
instance, the boundary line between skin and mucous membrane (anus, lips, 
margins of the lids, etc.). An additional factor giving rise to the development 
of epitheliomata at the limbus is probably furnished by the peculiar disposition 
of the epithelium at this spot, for we find here sometimes, even in the healthy 
eye, a proliferation of epithelium, the latter growing in the form of conical 
processes into the depth of the tissue. 

Sarcomata of the conjunctiva are, as a rule, pigmented. In this respect they 
are distinguished from the epitheliomata, although, as an extreme rarity, cases 
of pigmented epitheliomata do occur. Melanotic sarcomata, as is known, de- 
velop in those localities in which pigment is already normally present. They 
hence occur upon the conjunctiva of the lids, and above all upon the limbus, 
two divisions of the conjunctiva, which even under physiological conditions 
contain pigment. At the limbus particularly the quantity of pigment con- 
tained is sometimes so considerable in persons of the brunette type that even 
with the naked eye we notice in it either discrete dark-brown spots or a more 
uniform brown coloration. Spots of pigment occur sometimes also in other por- 
tions of the conjunctiva, both of the eyeball and of the lids, and from these 
spots melanotic sarcomata may subsequently develop. 

It is impossible to make a radical removal of epibulbar epitheliomata and 
sarcomata and at the same time preserve the eye, in cases in which these tumors 
have so great an extent superficially that the conjunctiva has to be extensively 
sacrificed ; for in that case there would occur as a result of the operation so 
extensive a formation of cicatricial tissue, with consequent distortion and fixa- 
tion of the eyeball, that the latter would become unserviceable for purposes of 
vision, and it would have been better to extirpate it at the beginning. So, 
also, the eyeball must be sacrificed in those cases in which the tumor grows 
down into the depth of the tissues at any one point — a thing which is especially 
apt to happen along the anterior ciliary vessels. Such an occurrence is often 
not discovered until after the removal of the superficial growth, or may even not 
be discovered at all. In the latter case a recurrence in the same locality occurs 
soon after the apparently radical removal. The following history serves to 
show the malignancy of these tumors which in the beginning are of such in- 
significant minuteness: 

In the year 1879 a woman, fifty-seven years of age, appeared in the eye- 
clinic, at that time directed by Arlt, having a melano-sarcoma on the right eye- 
ball. This had developed from a minute red spot which had already existed for 
a series of years, and which had begun growing larger the year before. It had 
the dimensions of a large pea, was of reddish-brown color, and was situated in 
the conjunctiva on the outer side of the cornea. The base of the tumor pro- 
jected from the limbus somewhat into the cornea, but nevertheless did not ex- 
tend into the pupillary area, so that the visual power was perfectly normal. I 
extirpated the tumor by cutting through the conjunctiva at a certain distance 
from the edge of the tumor, and then removed the latter as carefully as jjossi- 
ble from its base. The wound surface thus formed, which lay for the most 



DISEASES OP THE CONJUNCTIVA. 129 

part in the conjunctiva and to a smaller extent in the cornea, was scraped, and 
then the edges of the wound in the conjunctiva were united by a suture. 
Healing followed by first intention, and for a time the patient remained 
well. It was not till May, 1886— that is, seven years later — that the patient 
returned, having again an epibulbar melano-sarcoma on the right eye, which, 
however, this time was situated on the limbus at the inner side of the cornea, 
and formed a brown tumor half the size of a lentil. The thin cicatrix re- 
maining from the first tumor was still present, quite unchanged, at the outer 
margin of the cornea; the limbus at the upper and lower margins of the cornea 
also was quite normal. For this reason it was impossible to regard the melano- 
sarcoma, now situated at the inner corneal margin, as a recurrence of the tumor 
removed seven years before from the external corneal margin. In fact, it could 
only be referred to a disposition toward the formation of tumors, inherent in the 
limbus, so that after the removal of a tumor at one spot a similar one developed 
in another. (The same thing holds good for a case of epithelioma that I ob- 
served, which developed simultaneously and quite independently in both eyes, 
and in both at the inner margin of the cornea.) The small tumor was removed, 
and the place where it had been situated was superficially cauterized with the 
galvano-cautery loop. Recurrences, however, followed this extirpation in rapid 
succession. Four months later, in September, 1886, the woman returned with 
a recurrent growth at the upper corneal margin, and upon the removal of this, 
after another four months, two nodules formed in the conjunctiva to the inner 
and lower side of the corneal margin and at some distance from it. In order 
the more certainly to remove everything that was diseased, I resolved this time 
to enucleate the eye, although it was still serviceable for purposes of vision. 
In spite of this, a solid nodule made its appearance, not more than six months 
later, at the bottom of the orbit. The woman put ofl: having this removed, 
and did not come to the clinic until five months later. Meanwhile the glands 
in front of the ear, at the lower jaw, and on the anterior aspect of the neck 
had become enlarged and could be readily felt. Although now a radical oper- 
ation, consisting of a complete exenteration of the orbit and the removal of all 
discoverable glands, was performed, nevertheless only a few months afterward 
enlarged glands were again observed. Since then (in February, 1890) the 
woman has succumbed to an extension of the growth to the internal organs. 

Fibromata, osteomata (which are commonly congenital), myxomata, cylin- 
dromata, and lymphangiomata, although of very rare occurrence, should also be 
mentioned as tumors of the conjunctiva. 



The plica semilunaris and the caruncle which is situated upon it participate 
in the inflammations of the conjunctiva, so that it is unnecessary to treat of the 
disease of these parts separately. Sometimes the little hairs which the caruncle 
always has upon it are so long as to irritate the eye ; in that case the hairs must 
be epilated. The new formations of the caruncle are designated by the old 
name encanthis ; * benign new formations, such as simple polypoid or papillary 
outgrowths of the caruncle, are called encanthis benigna; malignant new for- 
mations are called encanthis maligna. 



* From iv, in, and Kovfliis, angle of the eye. 



CHAPTEE II. 

DISEASES OF THE CORNEA. 

Anatomy. 

27. The cornea, together with the sclera, represents the outer fibrous 
envelope of the eyeball, of which the cornea forms the transparent por- 
tion. Seen from in front, the cornea has the form of a horizontal 
ellipse, the horizontal diameter of its base, which is twelve millimetres, 
surpassing the vertical diameter, which is eleven millimetres. It is 
thinner in the center than at the edges, where its thickness amounts 
to about one millimetre. Hence it follows that the curvature of the 
posterior surface is somewhat greater than that of the anterior. The 
latter has a radius of curvature of 7.5 millimetres. Since the radius of 
curvature of the whole eye is more than this — amounting, in fact, to 
twelve millimetres — the curvature of the cornea is greater than that of 
the rest of the eyeball ; the cornea therefore is placed like a watch 
crystal upon the sclera. The same comparison also obtains for the 
method in which the cornea is inserted into the sclera ; for, in its pos- 
terior layers the cornea extends farther toward the periphery than in 
the anterior, where the sclera, as it were, laps over the edge of the 
cornea (Fig. 23). The microscope, however, does not show any sharp 
boundary line between cornea and sclera ; on the contrary, the fibers of 
one pass continuously into those of the other. 

The healthy cornea is transparent. Almost all morbid changes of 
the corneal tissue make themselves known at once by a diminution of 
this transparency. In advanced age, however, a cloudiness makes its 
appearance even in the healthy cornea (arcus senilis corne® or geron- 
toxon*). This consists of a narrow gray line which runs near the cor- 
neal margin, and is concentric with it. It shows itself under the form 
of a gray arc, first at the upper, soon after at the lower, margin of the 
cornea ; finally the two arcs unite at the outer and inner side of the 
cornea to form a closed ring. The outer boundary of the arcus senilis 
is sharply defined, and is separated from the limbus by a strip of per- 
fectly clear cornea ; on its inner aspect, or the one turned toward the 
center of the cornea, on the other hand, the cloudiness gradually shades 
away until it is lost in the transparent cornea. 

* From yipav, an old man, and t((Jo(/, bow. 
130 



DISEASES OP THE CORNEA. 



131 



The cornea consists of the following layers : 

1. The anterior epithelium (Fig. 35, E). This is a pavement epi- 
thelium consisting of several layers; the lowermost cells (foot cells, 
Fig. 29, «) are cylindrical, then 
follow rounded cells (Fig. 29, 
'/«), and finally flat cells (Fig. 
39, o). . 

3. Bowman's memlirane 
(lamina elastica anterior, Fig. 
35, B). This is a thin, homo- 
geneous membrane intimately 
connected with the lamella of 
the cornea lying beneath it. It 
may be said to represent the 
uppermost layer of the stroma 
of the cornea, which has be- 
come homogeneous and desti- 
tute of cells. From the epi- 
thelium it is separated by a 
sharply defined border ; and, 
under pathological conditions 
as well as after death, the epi- 
thelium separates very readily 
from Bowman's membrane. 

3. The stroma (Fig. 35, S). 
Til is is composed of a ground 
substance and of cells. The 
ground substance in its ulti- 
mate constitution consists of 
fine fibrillre of connective tis- 
sue, united by a cement sub- 
stance into flat bundles. The 
bundles are so applied to one 
another that lamella? (Fig. 35, /) are produced ; by the arrangement of 
these lamellffi in layers one above another, the cornea is built up. The 
latter has, therefore, a laminated structure. The individual lamella;, 
however, are not sharply separated from each other, but are connected 
by the interchange of bundles at frequent intervals. Hence, when we 
attempt to strip off the individual lamella; of the cornea, we find that 
this can not be done smoothly, but only with the simultaneous lacera- 
tion of the numerous connecting fibers. 

In many places between the individual bundles of the cornea, and 
also between the lamella; formed from the bundles, open spaces of 
greater or smaller size exist, which are filled with lymph and are 
hence called lymph spaces (seen in surface view in /, Fig. 36, and in 




Fig. 35. — Cross-section through a Normal Cornea. 
Magnified 100 x 1. 

i?, anterior epithelium ; i?. Bowman's membrane ; 
.S', stroma, composed of the corneal lamellae, ?, 
and the corneal corpuscles, K\ D. Descemet's 
membrane; e, posterior epithelium ; ji, nerves 
extending through Bowman's membrane and 
the epithelium. 



132 



DISEASES OF THE EYE. 



cross-section in K, Fig. 35). These are connected with one another 
by numerous minute canals (lymph canals, Fig. 36, C), and in this 
way constitute a continuous system of hollow passages, or system of 
lymph passages, permeating the cornea in every direction. This sys- 
tem is designed for the circulation of the lymph, and is of the greatest 
importance for the cornea, for, as the cornea does not possess any 
blood vessels, it is forced to depend for its nourishment solely upon its 
system of lymph passages. 

The cells of the stroma of the cornea, the corneal corpuscles, are 
contained in the spaces of the lymph system, and are of two kinds — 
non-motile and motile cells. The former are the fixed corpuscles of 
the cornea. They are cells with a large nucleus and a very flat, proto- 
plasmic cell body, and they lie in 
the lymph spaces, to whose ante- 
rior or posterior wall they attach 
themselves (P, Fig. 36). Proto- 
plasmic processes extend from 
their cell body into the lymph 
canals which start from the lymph 
spaces. These processes anasto- 
mose with the processes of neigh- 
boring fixed corneal corpuscles, 
so that in this way there is formed 
a system of connected protoplas- 
mic bodies (cells and their pro- 
cesses). We have thus in the cor- 
nea two connected systems — a 
positive one formed of protoplasm, 
and a negative one consisting of 
hollow passages (lymph spaces 
and lymph canals). The former 
system lies wholly within the latter, and, together with it, permeates 
the entire cornea. The protoplasmic system, however, nowhere com- 
pletely fills the cavity of the system of passages ; the space which is 
left unfilled is occupied by the circulating lymph. 

The second variety of cells belonging to the stroma are the motile 
corpuscles of the cornea (wandering cells), which were discovered by 
Kecklinghausen. These are nothing but white blood corpuscles which 
have made their way into the cornea, and which move about in its sys- 
tem of lymph passages. In the normal cornea they are present in very 
small amount ; but whenever any irritation acts upon the cornea they 
at once increase considerably in number, since they escape from the 
network of blood-vessels forming the marginal loops and pass into the 
cornea. These cells play an important part in inflammation of the 
cornea. 




Fig. 36. — Lamellae of the C ^rnea (Surface 
View). - (After Waldeyer.) 

In contrast with the ground substance, ff, which 
Is shaded in the drawing;, are the light-col- 
ored lymph spaces, 7, connected with each 
other by the lymph canals. C. Lying in the 
lymph spaces, without entirely filling them, 
are the protoplasmic bodies ( P) of the cor- 
neal corpuscles provided with the cell nu- 
cleus, K. 



DISEASES OP THE CORNEA. I33 

4. Descemefs memirane {D, Fig. 35) is a homogeneous, hyaloid 
membrane whicli forms the posterior boundary of the cornea. Unlike 
Bowman's membrane, it is quite sharply separated from the stroma of 
the cornea, from which also it is chemically different. It is very re- 
sistant to chemical reagents, and likewise to pathological processes 
going on in the cornea. When the entire stroma of the cornea has 
already broken down into pus, we often see the thin Descemet's mem- 
brane still for days offering resistance and remaining unimpaired (see 
§33). 

5. The posterior epithelium (endothelium, e. Fig. 35). This, under 
the form of a single layer of flattened cells, coats the posterior surface 
of Descemet's membrane. 

The cornea at its margin abuts against three membranes, the con- 
junctiva, the sclera, and the uvea (iris and ciliary body). Embryology 
teaches us that the cornea consists of three superimposed layers, each 
of which corresponds to one of the membranes adjacent, and may be 
said to represent its continuation over the most anterior portion of the 
eyeball. The cornea hence consists of three divisions — a conjunctival, a 
scleral, and a uveal. According to Schwalbe, the anterior epithelium 
forms the conjunctival portion of the cornea (the so-called conjunctiva 
cornese). Descemet's membrane, together with the posterior epithelium 
lining it, belongs to the uvea, while the entire stroma of the cornea, 
together with Bowman's membrane, represents the continuation of the 
sclera. In the fully developed eye these three divisions are fused into 
a common whole, although their community of origin with the adja- 
cent membranes still finds expression under pathological conditions; 
the conjunctival division suffering most of all in diseases of the con- 
junctiva, the uveal division in diseases of the uvea. 

The cornea contains no vessels. These cease at the margin of the 
cornea, forming there at the limbus the network of marginal loops, 
which is supplied by the anterior ciliary vessels (see page 41, and q, 
Fig. 22). From the marginal loops the blood plasma passes over into 
the system of lymph passages, by which the nutrition of the cornea is 
effected. 

The nerves of the cornea arise partly from the ciliary nerves, partly 
from the nerves of the bulbar conjunctiva. They are very numerous, 
particularly in the uppermost layers of the stroma, from which the 
nerve fibers pass forward through Bowman's membrane into the epi- 
thelium as far as the most anterior layers of the latter (Fig. 35, n). 
The cornea is therefore extremely sensitive to the touch. In the in- 
duction of narcosis the reflex that follows from touching the cornea 
(screwing together of the lids) is employed in order to test the depth 
of the narcosis, since this reflex is among those that are the last to 
disappear. Lesions of the cornea are particularly painful whenever 
they affect the uppermost layers which are so rich in nerves, as, for in- 



134 DISEASES OP THE EYE. 

stance, in the case of exfoliation of the epithelium, by which the numer- 
ous fibers of the epithelial plexus of nerves are laid bare. 

While the cornea, viewed from in front, appears elliptical, it is circular, if 
looked at from behind. Hence the elliptical form of the front surface of the 
cornea is due to the fact that both sclera and conjunctiva overlap it farther 
above and below than at either side. 

There is not yet perfect unanimity of opinion as to the division of the cornea 
into three layers. Waldeyer liolds a different view from that represented in 
the text, regarding as the conjunctival portion the anterior epithelium, Bow- 
man's membrane, and the most anterior of the lamellae of the corneal stroma; 
the uveal portion would then be formed by the posterior epithelium, Descemet's 
membrane, and the most posterior of the lamellas of the corneal stroma, so that 
only the middle lamellae of the cornea would be left to form the scleral portion 
(cf. Fig. 89). 

The older authors ascribed an important part in the nutrition of the cornea 
to the aqueous humor, which was supposed to be constantly soaking through 
it, and thus supply it with nourishment and provide for the maintenance of 
its transparency. From experiments, performed especially by Leber, this view 
must be considerably modified. An exchange of fluid between the parenchyma 
of the cornea and the aqueous humor is conceivable as occuri-ing in two ways : 
by diffusion, which takes place only by means of diosmosis, and by the more 
rapid process of filtration, in which the fluid passes through comparatively large 
gaps in the tissue. The first sort of interchange — that, namely, by diffusion — 
is the only one that takes place in the healthy cornea; and the aqueous humor 
which gets into the cornea in this way may contribute to the nutrition of its 
posterior layers. Diffusion may also occur in the reverse direction— that is, 
from before backward. If, for instance, a solution of atropine is dropped upon 
the cornea, atropine is found a short time afterward in the aqueous humor. 
But interchange of fluids by flltration does not occur in the normal cornea. 
Leber has shown that it is the posterior epithelium which opposes the filtration 
of fluids. If this is removed, the aqueous humor penetrates in considerable 
quantity into the cornea, which in consequence becomes cloudy and swollen. 

Clinical Examination of the Cornea. 

28. An examination of the cornea must have regard to the follow- 
ing points : 

1. The size and form of the cornea. Both may be altered either 
in consequence of congenital defects or because of morbid processes. 
Overlapping of the cornea by the limbus to an unusual extent, or the 
presence of marginal opacities in the cornea, not infrequently simulates 
a diminution in size or an irregularity of form. 

3. The surface of the cornea must be examined with regard to its 
curvature, its evenness, and its polish. In respect to (a) the curvature 
of the cornea as a whole, marked anomalies are recognizable at the first 
glance ; slighter changes, however, require more precise examination by 
means of the reflex images (see page 2). The cornea acts as a convex 
mirror, the greater the curvature of which the smaller is the reflected 



DISEASES OP THE CORNEA. 



135 



.-J 



^ 






®' 



«A 






6' 



image. In order to be able to Judge whether the reflex image given 
by a particular cornea is of abnormal dimensions, we must compare it 
with the image reflected from another cornea which is healthy, and 
most conveniently with that from 
the cornea of the other eye, in case 
it is normal. The diagnosis is easy 
when the curvature varies at differ- 
ent portions of the same cornea (as, 
for instance, in keratoconus, in which 
the central portions have a greater 
curvature than those at the periph- 
ery). In such a case we cause the 
eye to move about in such a way 
that the reflection of a window op- 
posite falls successively upon differ- 
ent portions of the cornea, and then 
we see the reflex image becoming 
larger or smaller according to the 
varying curvature of the cornea. 
The evenness (b) of the corneal sur- 
face, together with the perfection of 
its polish, gives to the normal cor- 
nea its brilliant luster. Here again 
the reflex images afford the best 
means of testing both of these prop- 
erties. These images lose their reg- 
ularity of form at the place where 
the cornea is uneven ; they appear 
distorted, owing to their outlines 
being irregularly bowed in or out. 
The form and extent of the in- 
equality may be deduced from the 
kind of distortion of the reflex 
image. By the ophthalmoscope, 
too, we can recognize inequalities of 

the corneal surface, on account of the irregular astigmatism which they 
produce (page 18). The uneven spots upon the corneal surface are 
either depressions (losses of substance) or elevations. Furthermore, 
the cornea may be uneven from being wrinkled (rhytidosis* corneas) 
or from being entirely collapsed (collapsus cornese). Both of these 
conditions occur in cases of great diminution in the tension of the e3'e- 
ball, hence particularly after the escape of the aqueous or vitreous 
humors. If (c) the polish of the cornea is entirely lost, the latter 



Fig. 37.— Corneal Epithelium in a Case op 
Increase of Tension. Magnified 500 x 1. 

The specimen was from a case in which in- 
crease of tension set in after iridocyclitis. 
C, parenchyma of the cornea with the 
flat nuclei of the corneal corpuscles. B, 
Bowman's membrane, through which in 
two places fine nerve filaments are seen 
passing. At the anterior ends of these 
nerve filaments and also at other spots 
there are seen between the bases of the 
lowermost cylindrical cells (foot celis) 
light-colored rounded spaces, which rep- 
resent very minute droplets of liquid. 
The lines of division between the foot cells 
are in general represented by lighter col- 
ored lines, which indicate that the cells 
are to a certain extent pressed apart by 
fluid and their interconnections broken 
up. On the other hand, the cells of the 
middle layer are bordered by broad, dark 
lines corresponding to the interlocking 
teeth of these, the pectinate cells. In the 
uppermost layers there are numerous 
cells altered by imbibition of fluid. In the 
cell a this fluid occupies the greater part 
of the cell body, so that the cell itself is 
enlarged. At b the anterior wall of a cell 
that was filled with fluid has fallen off. 
At c t'le liquefied contents of a cell have 
been evacuated through a slender open- 
ing. Owing to these changes in the up- 
pcimost cells, the surface of the epithe- 
luim as a whole is uneven. 



* From pvrisy a wrinkle. 



136 DISEASES OP THE EYE. 

becomes lusterless (dull) ; it looks like glass that has been breathed 
upon, or looks as if it had been smeared with grease. The reflex images 
show their normal size and form, but have lost their sharp outline. 
Lack of luster of the cornea is also caused by the. presence of inequali- 
ties so minute as to be nearly or quite imperceptible to the naked eye. 
Such inequalities may consist either of elevations or depressions. The 
latter are produced by the detachment of isolated epithelial cells in a 
number of places, thus leaving minute excavations (Fig. 37, b) ; the 
surface of the cornea looks as if stippled by needle pricks. In other 
cases we see the roughness of the cornea produced in the opposite way 
— that is, by its surface being covered with numerous small elevations, 
in which case the cornea looks as if it were made of shagreen. Here we 
have to do with multiple elevations, produced by a lifting up of the 
epithelium, and occurring under the form of minute vesicles. 

.3. The transparency of the cornea is a property which belongs to 
its parenchyma, not its surface ; which latter, in fact, is only a mathe- 
matical concept, an expression for the superficial space bounding the 
cornea and lying between it and the air. 

Dense opacities of the cornea are visible from a distance ; but for 
the recognition of slight opacities, lateral illumination, and often also 
the use of the magnifying glass, are indispensable. By means of these 
aids to diagnosis we determine the form, extent, and denseness of the 
opacity. We make out whether it is found in the superficial or in the 
deep layers of the cornea, and further whether it is diffuse or is com- 
posed of separate small points, spots, or strife. Many an opacity which 
appears diffuse when seen with the naked eye proves, when looked at 
with the magnifying glass, to be compounded of smaller opacities. 
Such an opacity may subsequently become really homogeneous by the 
enlargement and confluence of its components. 

4. The sensitiveness of the cornea is tested by touching it with the 
end of a thread or a shred of paper. In many diseases the sensitiveness 
of the cornea is diminished, or is abolished altogether. 

I. Inflammation- of the Coknea. 

General Statement. 

29. In the course of an inflammation of the cornea (keratitis *) we 
observe the following stages. The inflammation begins with an infil- 
trate (Fig. 38). Cells in increased number make their appearance 
within the parenchyma of the cornea, and these constitute the exudate. 
As a consequence of this the diseased part loses its transparency. The 
level of the cornea remains normal at this spot, only the epithelium 
suffers to the extent of losing its polish, so that this portion of the cor- 

* From Kepas, horn. 



DISEASES OF THE CORNEA. 



137 




FlQ, 



■Infiltrate in the Cohnea. (After Saemisch.) 



The epithelium, e, and Bowman^s membrane, b, over the 
infiltrate are preserved. 



nea appears dull upon the surface. The clinical signs of the existence 
of an infiltrate hence are cloudiness of the cornea, and loss of luster 
over the clouded portion, 
but no unevenness of the 
surface. The subsequent 
fate of the infiltrate varies. 
It may go on to resorption 
or to suppuration. 

(a) Resorption occurs 
in those cases in which the 
accumulation of exudate 
between the lamellae of the 
cornea is not excessive, so 
that the lamellae of the cor- 
nea are not broken down 
by reason of its presence, 
and hence there is nowhere produced any destruction of the tissue of 
the cornea itself. In this case the resorption of the exudate represents 
the second or regressive stage of the inflammation, and with it the 
morbid process comes to a conclusion. In favorable cases, when the 
cells constituting the exudate have disappeared by resorption, the dis- 
eased spots may become perfectly normal once more and regain their 
transparency (healing without permanent sequelae — i. e., without opaci- 
ties). But it may also hap- 
pen that the stroma of the 
cornea may not be abso- 
lutely destroyed by the 
deposition of the exudate, 
and may yet have experi- 
enced such an alteration 
of its structure that, even 
after the disappearance of 
the exudate, it never again 
becomes perfectly transpa- 
rent. Or it may be that 
the exudate deposited be- 
tween the lamellae of the 
cornea does not disappear 
completely by resorption, 
but in part becomes organ- 
ized and is left permanently fixed in the cornea. In both of these cases 
the infiltrate disappears by a process of healing, but leaves a permanent 
opacity behind. All those cases in which resorption of the exudate oc- 
curs without breaking down of the corneal stroma are grouped together 
under the common name of nonsuppurative keratitis. 




Fig. 39.— Corneal Ulcer in the PRoaRESSrvE Stage. 
(After Saemisch.) 

The base of the ulcer is formed by an accumulation of 
pus cells, which also push their way some distance in 
between the lamella of the cornea that adjoin the 
ulcer. At the edges of the ulcer, which are somewhat 
raised, the epithehum, e, and Bowman's membrane, 
6, end as if cut short off. 



138 



DISEASES OP THE EYE. 




(b) The infiltration goes on to siippuration, when the exudation is 
such as to be no longer compatible with the maintenance of life by the 
corneal stroma, so that the latter breaks down. The inflammation then 
enters upon its second stage, that of suppuration, which is associated 
with a localized destruction of the cornea. These cases of keratitis are 
known as suppurative keratitis. 

The most frequent form of suppurative keratitis is the corneal ulcer 
in which the process of purulent disintegration begins in the most 
anterior layers of the cornea (Pig. 39). In this way a superficial loss of 

substance is produced 
which is recognizable 
as a depression in the 
corneal surface. In 
the beginning, the loss 
of substance repre- 
sents only those parts 
which are most mark- 
edly infiltrated, and 
hence are the first to 
break down. Sur- 
rounding these are lay- 
ers, which likewise are 
infiltrated with the ex- 
udate, although not 
to as high a degree. 
Hence both the floor 
and the walls of the 
ulcer are still infiltrated, for which reason we call it a foul (coated, 
infiltrated, or progressive) ulcer. Later on the infiltrated portions 
forming tlie floor and the wall of the ulcer, so far as they are incapable 
of living, are also cast off ; but those parts of the corneal tissue which 
have retained their ability to live remain, are freed by a process of 
resorption from the exudate which infiltrates them, and become once 
more transparent. The ulcer has, it is true, become somewhat larger 
than before, but the cloudiness surrounding it has disappeared ; the 
ulcer has acquired a smooth, transparent base and edges ; it is a 
cleansed {regressive) ulcer (Fig. 40). ' 

Among the clinical signs by which we diagnosticate an ulcer, the 
most important is the unevenness of the corneal surface, the latter 
presenting a depression or loss of substance. In foul ulcers this de- 
pression is surrounded by clouded corneal tissue, which, moreover, is 
dull upon its surface ; the floor of the ulcer also is gray and uneven. In 
clean ulcers the cloudiness surrounding them is very slight, or is want- 
ing altogether, and the floor and edges of the loss of substance are 
smooth and shining; the ulcer gives a mirrorlike reflex. 



Fig. 40. — Corneal Ulcer in the Regressive Stage. 
(After Saemisch.) 

The base of t]ie ulcer is formed by the denuded lamellse of the 
cornea ; a sli2:ht increase in the number of cells between 
them can still be made out. At the edges {b) of the ulcer 
the epithelium, e, is beginning to grow out over the base. 
Newly formed blood-vessels (g), lying in the upper layers of 
the cornea, run to the ulcer. 



DISEASES OP THE CORNEA. 



139 




Fig. 41.— Cicatrix of the Cornea. (After Saemisch.) 

The epithelium, e, is everywhere present, but over the cica- 
trix it is irregular, and in places (at a) is thickened. Bow- 
man's membrane. 6, is wanting at the site of the cicatrix. 
The latter itself is distinguished from the tissue of the 
normal cornea by its denser and less regular texture. 



Every keratitis suppurativa entails a loss of substance in the cornea. 
This must be filled up again by newly formed tissue, in doing which 
the process enters upon 

its third stage — that of ^ 

cicatrization. The new- 
ly formed tissue is not 
corneal tissue, but con- 
nective tissue, and is ac- 
cordingly opaque (Fig. 
41). Hence suppurative 
keratitis always leaves a 
permanent opacity after 
it. The opacity, indeed, 
is the principal clinical 
sign of a cicatrix, for 
the corneal surface has 
completely reacquired 
its luster, because its 
epithelium is restored to 
the normal state, and the excavation or loss of substance has disap- 
peared, at most a slight flattening of the surface being present. 

Kecapitulation. — As has been stated above, non-suppurative kerati- 
tis has two stages, the stage of infiltration and that of resorjDtion. In 
suppurative keratitis, on the other hand, we distinguish three stages : 
the stage of infiltration, the stage of suppuration, and the stage of 
cicatrization (reparation). The stage of suppuration is composed of 
two periods, the progressive period (foul ulcer) and the regressive pe- 
riod (clean ulcer). 

In the clinical diagnosis of the form and the stage of an inflamma- 
tion of the cornea we proceed in the following manner : We first ex- 
amine the corneal reflex. If the surface is dull, we are dealing with a 
recent affection, and in that case, if there is no loss of substance, with 
an infiltrate; hut if a loss of substance is present, with a foul ulcer. 
If the surface is lustrous, the affectioti is an old one, and, if a loss of 
substance is present, is a clean ulcer ; but if no loss of substance is 
visible, we are dealing luith a cicatrix. 

30. Vascularization of the Cornea. — In inflammations of the cornea 
we very frequently observe the development of vessels which grow in 
upon the cornea from its margin. This occurs most frequently during 
i\\& 2:irocess of healing of corneal ulcers. At the time when the ulcer 
begins to become clean, we see vessels starting out from that part of 
the limbus lying next to the ulcer. These vessels lie in the most su- 
perficial layers of the cornea and extend toward th« ulcer, whose edges 
they soon reach (Fig. 40, g). Their chief office seems to consist in 
supplying the necessary material for filling in the loss of substance. 



140 DISEASES OF THE EYE. 

Their ad rent is therefore to be regarded as a favorable occurreuce ; we 
know that at the spot where the vessels have reached the ulcer the 
further progress of the latter is ao longer to be apprehended — that, on 
the contrary, it will there enter upon the process of healing. After 
the loss of substance has been filled in the vessels gradually disappear, 
so that a corneal cicatrix contains fewer and fewer of them as it be- 
comes older. Nevertheless, the blood-vessels never entirely disappear 
from the large cicatrices. 

In other cases the formation of new vessels accompanies the prog- 
ress of the inflammatory process, and hence belongs, like the exuda- 
tion itself, to the clinical picture of the inflammation. The best exam- 
ple of this is afforded by the vascular form of parenchymatous keratitis 

(§ 41)- 

A kind of vascularization differing from both of these varieties is 
that which forms one of the symptoms of panniis. Here the vessels 
do not lie in the cornea itself, but in a newly formed tissue which is 
deposited upon the cornea and of which they form an essential constit- 
uent (Fig. 27). 

It is very important to determine the situation of the vessels in the 
cornea — that is, whether superficial or deep — since by this fact alone 
we can often diagnosticate what sort of keratitis we are confronted 
with. The type of superficial vascularization is afforded by paunus, 
that of deep vascularization by keratitis parenchymatosa. 

The signs which enable us to distinguish the two kinds of vasculari- 
zation from each other may be contrasted as follows : 

SuPEEFioiAL Vessels Deeply situated Vessels 

(Fig. 42) (Pigs. 43, 44) 

spring from the network of mar- spring from the vessels of the 
ginal loops of the. limbus, andean sclera close to the margin of the 
therefore be followed from the cor- cornea, and hence appear to come 
nea into the limbus, and thence on to an end suddenly at the limbus, 
to the vessels of the conjunctiva. as they disappear behind the latter 

to enter the sclera. 
On account of their superficial Are not distinctly recognizable, 
position are clearly visible and well- or are even unrecognizable, except 
defined, and have a vivid-red color, as a diffuse red coloration, and 

have a dirty-red (grayish-red) hue ; 
the reason for both of these appear- 
ances being that the vessels are 
veiled by the clouded layers of cor- 
nea lying in front of them. 
The vessels branch in an arbo- The vessels form fine twigs 

rescent fashion. which run parallel to each other 

(besom form of branching). 



DISEASES OF THE CORNEA. 



141 



The surface of the cornea is 
uneven, from the fact that the ves- 
sels raise up the epithelium that 
lies directly over them. 



The surface of the cornea is 
lusterless, it is true, but not un- 
even. 






Fig. 42.— Supekficial Blood- 
vessels IN Pannus. Mag- 
nified 8x1. 



Fig. 43.— Dkep-ltinq Blood- 
vessels IN Parenchyma- 
tous Keratitis. Magnified 
3x1. Recent case with 
penicillate branching. 



Fig. 44.— Deep-lying Blood- 
vessels IN Parenchyma- 
tous Keratitis. Magni'fied 
2x1. Old case with besora- 
like branching of vessels. 



Participation of Neighboring Organs in the Process. — Every kera- 
titis is accompanied by inflammatory symptoms, the most important of 
which is — ■ 

(a) The injection of the blood-vessels. The characteristic mark of 
corneal inflammation is ciliary injection. When the inflammation is 
great, conjunctival injection also makes its appearance, and may con- 
ceal the ciliary injection to a greater or less extent. Very violent sup- 
purative inflammations of the cornea are accompanied by cedematous 
swelling of the conjunctiva and even of the lids. 

{b) The iris and even the ciliary body become inflamed in cases of 
marked keratitis, so that we see the symptoms of iritis and iridocyclitis 
set in (see §§ 67 and 68). These accompanying inflammations may be 
intense enough to bring about the destruction of the eye. 

(c) Hypopyon * is the accumulation of a purulent exudate at the 
bottom of the anterior chamber. It forms a frequent symptom in 
keratitis suppurativa. We then find collected in the lowest portion of 
the chamber a yellow mass which, because it is fluid, is limited above 
by a horizontal line, and for the same reason is seen to change its 
place and seek the deeper portions of the chamber when the head is 
moved. In other cases the mass is viscid or pultaceous, so that when 
seen from in front it has a border that is convex upward, or it lies quite 
like a solid ball at the bottom of the chamber and does not change its 
position with the movements of the head. The quantity of the pus 
produced in this way varies greatly, ranging from a scarcely perceptible 
crescent lodged in the lowest sinus of the chamber up to masses of such 
size that the entire chamber is filled by the hypopyon. Hypopyon may 



* From vir6, beneath, and viov, pus. 



142 DISEASES OF THE EYE. 

disappear by resorption, this process taking place the more rapidly the 
more fluid the hypopyon is. Pretty thick masses of exudation may 
become organized and lead to occlusion of the pupil, or, in rare cases, 
to adhesion of the iris to the posterior surface of the cornea. 

(d) The subjective phenomena associated with keratitis are pain 
and photophobia, together with the lachrymation and blepharospasm 
which these conditions cause, and also disturbance of vision — symp- 
toms which are met with in very varying degree. 

The Mstological processes occurring in inflammation of the cornea have been 
the subject of the most zealous investigations, and especially of investigations 
experimentally conducted, because the attempt was made to study in this field 
the problem of inflammation in general. For such studies the cornea is par- 
ticularly adapted on account of its transparency, and also on account of the 
characteristic form of the fixed elements of its tissue. There is no doubt that 
in every keratitis there occurs an increase in the number of the cellular elements, 
whose accumulation causes the cloudiness of the cornea, visible to the naked 
eye, and finally, if very considerable, terminates in the formation of pus. Never- 
theless observers could not agree as to the source of the new cells which made 
their appearance in the cornea. Some, the leader of whom was Cohnheim, 
look upon them as white blood corpuscles which have migrated into the cornea 
from the vessels of the corneal margin. Others, and especially Strieker, con- 
sider them derived from an increase in number of the normal fixed cells of the 
cornea. It is certain that both processes occur, although a different significance 
attaches to the two. Whenever an irritant productive of inflammation affects 
the cornea numerous white blood corpuscles wander into the latter. These 
are derived from two sources: In part they originate from the conjunctival 
sac, getting from there into the affected region of the cornea, because the epi- 
thelium here is lacking; in part they arise from the vessels of the corneal mar- 
gin, from which they make their way between the lamellse of the cornea until 
they reach the inflamed spot. The cells derived from the corneal margin in 
certain cases form a ring-shaped infiltration (invasion ring) about the diseased 
area, giving to the latter, especially in the case of ulcus serpens, a characteristic 
appearance. The white blood corpuscles that have emigrated from the net- 
work of marginal vessels into the cornea form the main mass of the exudate. 
On the other hand, the fixed corneal corpuscles, while taking but an insignifi- 
cant part in the formation of the exudate, do produce by their proliferation 
most of the material for the reparative process, that follows the inflammation, 
and which results in the development of new tissue. 

In the healing of the losses of substance produced by inflammation, the re- 
generation of the epithelium and the regeneration of the stroma of the cornea 
require separate consideration. The epithelium of the cornea is replaced by 
the growth of the epithelium from the edge of the ulcer. Losses of substances 
which affect the epithelium only, heal with a perfect restoration to the normal 
state and without leaving a permanent opacity. On the other hand, every loss 
of substance of the corneal stroma is filled up by cicatricial tissue which forms 
from the bottom and sides of the ulcer. The chief part in this is taken by the 
fixed cells of the cornea in the immediate neighborhood of the ulcer as these 
increase by division, and the cells which thus arise grow into connective-tissue 



DISEASES OF THE CORNEA. I43 

fibers. The tissue thus formed is, however, essentially different from the normal 
tissue of the cornea (Fig. 42). The regular arrangement of the normal fibers 
of the cornea is wanting, and so, too, are the stellately branched fixed corneal 
corpuscles, which are replaced by ordinary connective-tissue cells. Bowman's 
membrane (Fig. 41, b) is never regenerated. The epithelium (Fig. 41, e) hence 
lies directly upon the cicatricial tissue, from which, being thinner in some places 
and thicker in others, it is separated by an irregular line. 

As a consequence of these peculiarities, the cicatricial tissue never possesses 
the perfect transparency of the normal cornea, and is hence recognizable even 
with the naked eye as an opacity. After having existed for a long time, the 
texture of the cicatricial tissue approximates somewhat more closely to the 
regular structure of the corneal tissue. It accordingly gains in transparency, 
and a " clearing up " of the opacity is observed to take place — a process, how- 
ever, which never gets to the point of producing a complete disappearance of 
the opacity except in the case of quite small and superficial cicatrices. 

In deep losses of substance the restoration of the normal epithelial coating 
does not delay making its appearance until the ulcer itself has been completely 
filled up by cicatricial tissue. On the contrary, from the moment when the 
ulcer has become clean the epithelium begins to grow over the latter, and 
hence begins to cover it at a time when there is no cicatricial tissue jiresent, or 
only a very thin layer of it (Fig. 40, at 6). At this time the ulcer (on account of 
the absence of opaque cicatricial tissue) is still almost completely transparent, 
and, as a consequence of the restoration of the epithelial covering, is smooth 
and shining. The formation of cicatricial tissue now goes on beneath the epi- 
thelium, and by this process the latter is gradually lifted up to its normal level. 
In proportion as the layer of cicatricial tissue becomes thicker, the degree of 
opacity naturally increases ; but it would be a very great mistake for the physi- 
cian to conclude from this fact that the disease was advancing. 

The signs before given, having regard to changes in the luster, evenness of 
surface, and transparency of the cornea, serve for the diagnosis of the variety of 
corneal disease that is present. They are not always, to be sure, found com- 
bined in a manner as schematic as has been represented. Some examples may 
show in what way exceptions to them occur. The opacities that are present 
upon the cornea may be old, and yet the cornea, because of a coincident in- 
crease of tension, may look dull and stippled. The surface of the cornea is not 
always smooth when there are infiltrates, nor yet when there are cicatrices. In 
the case of infiltrates, a bulging forward of the surface of the cornea often takes 
place on account of the deposition of an excessive quantity of exudation ; in the 
cases of cicatrices, on the other hand, a flattening may take place in consequence 
of an insuflicient filling in of the loss of substance. In doubtful cases, we must 
take still other factors into consideration, which may furnish points that will 
establish our diagnosis. Thus, in the case of a cicatrix, the outline of the 
opacity is commonly better defined than in the case of a recent opacity due to 
inflammation. The color of the latter form of opacity varies from gray to yel- 
lowish white and to yellow; cicatrices, on the contrary, present rather a pure 
white, or, if thin, a bluish-white hue. Recent inflammatory processes are asso- 
ciated with attendant inflammatory symptoms (ciliary injection, etc.), which 
are wanting in the case of cicatrices. By putting all these facts together the 
right diagnosis can almost always be made. 

Fluorescin is used to make more apparent those spots upon the cornea that 



144 DISEASES OP THE EYE. 

are destitute of epithelial covering (erosions and ulcers). If a one-per-cent so- 
lution of potassium fluorescin is instilled into the conjunctival sac, and then 
■washed out again with water, the highly fluorescent liquid penetrates solely 
into those portions of the cornea that are unprotected by epithelium, and such 
portions consequently are stained a vivid green. I use this method in clinical 
instruction to make small losses of epithelium more plainly visible ; but for the 
actual diagnosis of defects of the sort it is not necessary. 

The exudation into the anterior chamber, which accompanies every well- 
marked keratitis, depends upon the fact that irritant substances from the in- 
flamed cornea diffuse into the aqueous and then act upon the vessels of the 
uvea (i. e., the iris and ciliary body). As the first result of this, the aqueous, 
which under normal conditions contains only a trace of albumin, gets to con- 
tain such an amount of it that a layer of fibrin is precipitated upon the poste- 
rior surface of the cornea and often also upon the anterior surface of the iris 
(Figs. 90 and 99). In such cases the cornea, in addition to the circumscribed 
opacity that corresponds to the area diseased, presents over its entire extent a 
delicate diffused cloudiness produced by the layer of exudate upon its posterior 
surface. 

When the irritating substances produced by the inflammation are such as to 
excite a moi-e intense action, leucocytes pass out in considerable quantities 
from the vessels of the iris and ciliary body, and cause a cloudiness of the aque- 
ous, in which they become suspended. Later, by sinking to the bottom of the 
anterior chamber these cells form the hypopyon. The latter, therefore, origi- 
nates not from the cornea, but from the vessels of the uvea, as, indeed, is also 
apparent from the fact that many of the pus corpuscles contain pigment gran- 
ules, which they have transported with them from the inflamed uvea. 

Since the hypopyon has this origin, we understand why it is found to be 
free from pus cocci. It is owing to this freedom from germs that the hypo- 
pyon is tolerated by the tissues bordering the anterior chamber, and produces no 
special reaction in them. If ordinary pus containing cocci is injected into the 
anterior chamber of a rabbit, the eye is rapidly destroyed by panophthalmitis. 
But the pus that constitutes a hypopyon is not only tolerated by the eye with 
impunity, but can even undergo absorption without leaving any injurious effects 
behind. 

The resorption of the hypopyon takes place chiefly through the meshwork 
of the ligamentum pectinatum (§ 60). The rapidity with which absorption pro- 
ceeds varies exceedingly. In many cases a hypopyon of considerable size dis- 
appears so completely that after twenty-four hours scarcely a trace of it is to be 
found ; in other cases the hypopyon remains lying at the bottom of the cham- 
ber so long that it becomes organized. Sometimes we observe a rapid alterna- 
tion in the height of the hypopyon which at times decreases, and again increases 
once more. 

Subdivision of Keratitis. 

31. The subdivision of keratitis into keratitis suppurativa and kera- 
titis non-suppurativa corresponds most fully to practical requirements. 
Every suppurative keratitis, since it is associated with destruction of 
corneal tissue, leaves behind it a permanent opacity, which in many 
cases injuriously affects the visual power. On the contrary, so long as 
purulent dissolution of the cornea has not taken place — that is, in non- 



DISEASES OF THE CORNEA. 145 

suppurative keratitis — a complete restoration of its transparency, and 
with it of the normal power of vision, is possible, and, in fact, often does 
take place. Moreover, the above subdivision also corresponds to the 
essential characters of the corneal inflammations. For it is not merely 
a matter of accident whether an infiltrate in the cornea goes on to 
suppuration or to resorption. On the contrary, the forms which tend 
to the production of suppuration ordinarily present from the very be- 
ginning characters differing from those borne by forms in which there 
is no progress toward suppuration, so that these two categories are dis- 
tinct not only in their consequences but also in their clinical aspect. 
To each of the two categories a number of different forms belong, the 
most important of which are set forth in the following list : 

A. Keratitis Suppurativa. 

1. Ulcer of the cornea. 
3. Ulcus serpens cornese. 

3. Keratitis e lagophthalmo. 

4. Keratoma] acia. 

5. Keratitis neuroparalytica. 

B. Keratitis Non- Suppurativa, 
{a) Superficial forms. 

1. Pannus. 

2. Keratitis with the formation of vesicles. 
{I) Deep forms. 

3. Parenchymatous keratitis. 

4. Deep keratitis. 

5. Sclerosing keratitis. 

6. Keratitis starting from the posterior surface of the cornea. 



A. SuPFUBATivE Keratitis. 
1. Ulcer of the Cornea. 

32. Symptoms and Course.— Every ulcer of the cornea develops 
from a superficially disposed infiltrate. In the beginning we find one 
spot upon the cornea cloudy and the surfcce over it dull (infiltrate). 
Then the epithelium exfoliates upon the surface of the affected spot, 
and soon, by the breaking down of the most strongly infiltrated por- 
tions of the cornea, a loss of substance forms in the parenchyma of the 
cornea, so that an ulcer is produced. This is at first surrounded by 
infiltrated portions of the cornea— a fact which we recognize by the base 
of the ulcer being gray and uneven, and its walls likewise gray and 
clouded. The walls of the ulcer are often surrounded for quite a dis- 
tance by a gray area, or slender gray striae, extending from the ulcer in 
10 



146 DISEASES OF THE EYE. 

different directions into the transparent cornea. This is an unclean or 
progressive ulcer (Fig. 39). In a favorable case, only so much of the cor- 
neal tissue breaks down during the further progress of the disease as was 
from the very beginning too strongly infiltrated to live. In this case the 
ulcer rapidly becomes clean without attaining great dimensions. But it 
very often happens that, simultaneously with the breaking down of the 
parts that are most strongly infiltrated, the inflammatory cloudiness 
keeps spreading, new portions of the cornea being constantly attacked 
by the infiltration. And since these, too, break down into pus, the ulcer 
grows constantly larger. This progressive growth of the ulcer takes 
place sometimes more in the direction of its depth, sometimes more 
along the surface. In the former case, perforation of the cornea is to 
be apprehended; in the second case, larger and larger areas of the 
cornea may be destroyed and thus extensive opacities be produced. 
Progressive growth along the surface often takes place chiefly in one 
direction — a fact which can be easily recognized by a particularly 
marked gray cloudiness, or even a yellow cloudiness, of the ulcer wall 
on the corresponding side. It may even happen that the ulcer keeps 
constantly advancing in one direction, while on the opposite side it 
heals just as fast, so that it goes creeping over the cornea {serpigi- 
nous * ulcer). 

The progressive stage of the ulcer is accompanied by symptoms of 
irritation like ciliary injection, lachrymation, photophobia, and pain, 
which not infrequently reach a considerable height ; moreover, in this 
stage hypereemia and even inflammation of the iris make their appear- 
ance (evidenced by turbidity of the aqueous humor, hypopyon, dis- 
coloration of the iris, contraction of the pupil, posterior .synechia). 
There are, however, cases of ulceration in which the irritative symp- 
toms are very slight, or are wanting altogether — cases constituting what 
are called torpid or asthenic ulcers — which nevertheless may be very 
dangerous. 

When the infiltration has finally come to a standstill, the ulcer 
enters upon its regressive stage. The tissue that has been destroyed is 
cast ofl', that which has not been destroyed becomes transparent once 
more from resorption of the exudate. The ulcer "cleanses" itself 
(Fig. 40). A clean ulcer presents a smooth base and edges with little 
or no opacity, and is chiefly to be diagnosticated by the excavation of 
the surface of the cornea, which we recognize when examining the cor- 
neal reflex. In proportion as the ulcer becomes clean, the associated 
symptoms of irritation disappear. 

After the ulcer has become entirely clean, cicatrization begins. 
Vessels extend from the nearest portions of the limbus to the ulcer, 
which latter, in cousequenco of becoming filled with the. opaque mass 

* Prom serpere, to creep. 



DISEASES OP THE CORNEA. 



147 



of the cicatrix, becomes again more clouded, but at the same time con- 
stantly shallower, until finally it reaches the level of the adjacent nor- 
mal cornea. Not infrequently, however, the new formation of the cica- 
tricial mass comes to a standstill before the loss of substance has been 
quite filled up, so that the surface of the cicatrix remains permanently 
a little sunken. When such cicatrices are small they are, on account 
of the thinness of the cicatricial tissue, almost or quite transparent, and 
disclose their presence by a flattening of the cornea {corneal facet), only 
discernible upon examination of the corneal reflex. On the other hand, 
cicatrices not infrequently occur which project above the level of the 
surrounding cornea. Such are the cases in which the cornea at the 





Fig, 



Keratectasia produced by an Ulcer. Magnified 25 x 1. 



The thinned and protruding cicatrix is distingui.shed by its denser texture from the adjacent 
normal cornea. The epitheUum, *', over it is thickeiied, while Bowman's membrane. 6, is 
wanting. On the other hand, Descemet's membrane, d, with its epithelium, is everywhere 
present— a proof that the ulcer has not perforated. 

base of the ulcer, having become thinned, does not offer resistance to 
the intra-ocular pressure, and bulges forward. The bulging may disap- 
pear, owing to the contraction of the cicatricial tissue; but it may also 
remain permanently {ectactic cicatrix, keratectasia* ex ulcere. Fig. 45). 
The formation of ectactic cicatrices is, however, of much more frequent 
occurrence after perforation of the cornea. 

33. Perforation of the Cornea. — The course which an ulcer takes is 
much more complicated when the latter perforates the cornea. Per- 
foration takes place when the ulcer has penetrated down to the deepest 
layers of the cornea. The patient suddenly experiences violent pain, 
and feels a hot liquid (the aqueous humor) gushing out of the eye, 
after which, not infrequently, the severe pains previously existing sub- 
side. Perforation may occur spontaneously or in consequence of a 
sudden increase of the intra-ocular pressure, such as may be caused by 
bodily exertion (even, for example, stooping), or by coughing, sneezing, 
screwing together the lids, crying (in children), etc. The increase in 
intra-ocular pressure, which develops under these circumstances, is to 
be referred to two causes : it is partly a result of the increase of blood 



* From Ke'pos, horn, and cktoo-is, distention, from iRTiiveiv, to stretch out. 



148 DISEASES OF THE BYE. 

pressure (from the straining of the muscles, and also from congestion 
in the district drained by the superior vena cava), partly produced by 
direct compression of the eyeball, and particularly by the pressure 
which the ocular muscles, and especially the orbicularis palpebrarum, 
at such times exert upon it. The perforation produced by such causes 
may develop with violent symptoms and entail very damaging results. 

After perforation has occurred we find the anterior chamber obliter- 
ated in consequence of the escape of the aqueous humor ; the iris and, 
in the region of the pupil, the lens also are applied to the posterior 
surface of the cornea. If the aperture made by the perforation is of 
suitable position and size, we see lying in it the iris which has been 
swept into the wound by the jet of escaping aqueous. The eye feels 
quite soft. 

Perforation is often preceded by a heratocele* For, Descemet's 
membrane being distinguished by the great resistance which, in com- 
parison with the corneal lamellaB, it offers to the inflammatory process, 
it often happens that the stroma of the cornea is destroyed throughout 
its entire thickness by suppuration, while Descemet's membrane still 
remains resistant. In that case it is protruded by the intra-ocular 
pressure under the form of a transparent vesicle which is visible upon 
the floor of the ulcer, or which may even project above the level of the 
adjacent cornea (keratocele or descemetocele). When this vesicle, too, 
ruptures, the perforation becomes complete. Sometimes the ulcer heals 
without the keratocele either rupturing or being flattened out. The 
latter then remains permanently under the form of a vesicle which pro- 
jects above the surface of the cornea, and which, itself transparent, is 
surrounded by a cloudy, cicatricial ring. 

The direct effect of a perforation upon the course of the disease is 
for the most part favorable, inasmuch as not only the pain and the 
other symptoms of irritation abate, but the progress of the ulcer also 
is, as a rule, arrested, and the ulcer rapidly becomes clean. The reason 
for this favorable influence is probably to be looked for in the fact that 
after the escape of the aqueous humor the intra-ocular pressure sinks 
considerably, and the resulting diminution in the tension of the cornea 
facilitates the circulation in the latter. 

The method in which the perforation in the cornea closes again 
varies according as it is placed in front of the iris or the pupil. If the 
opening is found in front of the iris, as is generally the case, it is 
quickly covered by the iris, which, after the escape of tlie aqueous 
humor, is driven forward as far as the cornea. In this way it becomes 
possible for the anterior chamber to be restored within a very short 
time, although, to be sure, the iris at the site of the perforation remains 
permanently connected with the cornea. If the perforation is quite 

* From Kepas, horn, and lefiKri, rupture. 



DISEASES OP THE CORNEA. 



149 




Fie. 46. 



-Partial PKOLArsE of the Iris 
(Schematic). 



The iris, which is thickened by the process of infil- 
tration, and is covered on its anterior and pos- 
terior surface by the exudate, e, ej, rises up be- 
tween the sharp edges of the mnrgins of the 
perforation, which are still infiltrated. Periph- 
erally from the prolapse the iris is approxi- 
mated to the cornea, although here a remnant, 
V, of the anterior chamber still exists. 



small, the iris simply applies itself to it from behind and there becomes 
solidly adherent. In case, however, the perforation is larger, the iris, 
as a rule, is driven into it by the escaping aqueous humor, and thus a 
prolapse or liernia of the iris is 
produced (Fig. 46). This is 
represented by a hemispherical 
prominence which, while re- 
cent, has the gray or brown 
color of the iris. Soon, how- 
ever, this color is changed be- 
cause of a layer of gray exuda- 
tion (e, Fig. 46) which covers 
the prolapse like a cap, and 
may be removed with a forceps. 
When the prolapsed portion of 
the iris is much stretched, the 
proper color of the iris is lost 
and the prolapse looks black, 
because of the retinal pigment 

on its posterior surface, which appears through the thinned stroma. 
This is particularly often the case in large prolapses of the iris. The 
extent of the prolapse of the iris is proportional, first of all, to the size 
of the perforation. In the worst cases the perforation may comprise 
the whole cornea, which has suppurated throughout ; in that case the 
iris prolapses through its entire extent {total prolapse of the iris, Fig. 

47). The pupil is then gener- 
ally closed up by a plug of 
exudation {p). But the way 
in which the prolapse occurs 
has also an influence upon its 
size. If the perforation takes 
place with great force (e. g., 
while the patient is straining 
hard), or if the patient behaves 
in a restless manner after it 
has taken place, a relatively 
larger portion of the iris will 
be driven into the perforation. 
The cicatrization of a cor- 
neal ulcer, which is associated 
with a prolapse of the iris, oc- 




FiQ. 47.— Total Prolapse of the Iris (Schematic), 

Only the marginal portions, c, of the cornea are 
preserved, and these are still partially infiltrated. 
Between them bulges the iris, which is driven 
strongly forward and which consequently is 
thinned so that the pigment, i, upon its posterior 
surface shines through it and gives the prolapse 
a blackish hue. The pupil, p, is closed by a 
membrane. The space, h, between the ins and 
the lens is the enlarged posterior chamber. Of 
the anterior chamber only the shallow, slit-lilce, 
annular space, v, is left. This no longer commu- 
nicates anywhere with the posterior chamber 
(seclusio pupillse). 



curs in the following manner, 
if the prolapse is left to itself : The prolapsed iris in the first place 
becomes solidly agglutinated to the walls of the opening caused by the 
rupture, and wherever it is exposed it is converted by inflammation into 



150 , DISEASES OP THE EYE. 

a sort of granulating tissue, so that the prolapse soon loses the color of 
the iris and becomes grayish-red. Subsequently there develops from 
the proliferating tissue of the iris cicatricial tissue, which first becomes 
visible under the form of isolated gray bands. By the contraction of 
these latter, constrictions are formed upon the surface of the prolapse. 
As the formation of the cicatrix proceeds, these bands become broader, 
fuse together, and render the prolapse constantly flatter and flatter. 
Hence in favorable cases the process terminates in the formation of a 
flat cicatrix situated at the level of the rest of the cornea, and at the 
site formerly occupied by the bulging prolapse. This cicatrix being 
mainly a portion of iris that has become cicatricial, it follows that the 
remainder of the iris still lying in the anterior chamber is solidly 
united to it. Such an adhesion of the iris to a corneal cicatrix is called 
an anterior synechia* 

Owing to the fact that the iris is drawn forward to the scar, the 
pupil loses its round shape and is drawn in toward the site of the adhe- 
sion. To what extent tliis is the case depends upon where the perfora- 
tion is situated and what part of the iris is prolapsed. In peripherally 
situated ulcers, it is a portion of the ciliary zone of the iris that pro- 
lapses into the corneal wound. In this case the pupil is drawn strongly 
toward the site of the perforation ; it has the shape of a pear, the 
sharp end of which is directed toward the site of the synechia. If, how- 
ever, the perforation is situated near the center of the cornea, the pupil- 
lary portion of the iris becomes engaged in it in healing (Fig. 46), and 
in this case the distortion of the pupil is slight, or entirely absent. If 
the perforatiou is so large that the entire pupillary margin of the iris is 
involved in the prolapse and becomes attached to the cornea in healing, 
the pupil is permanently closed by the cicatrix that is formed ; there 
are produced occlusio and seclusio pupillse, together with their de- 
structive consequences. 

In the healing of large perforating ulcers of the cornea, the shrink- 
ing of the cicatricial tissue is often so great that the corneal cica- 
trix appears flattened when compared with the normal curvature of 
the cornea. This flattening, moreover, may extend beyond the cica- 
tricial spot to the portion of the cornea which is still transparent, and 
which in that case becomes flatter over its whole surface {applanatio - 
cornecs). If the cornea has been entirely destroyed by suppuration, 
so that a total prolapse of the iris has developed, the latter ulti- 
mately becomes reduced to a small and perfectly flat cicatrix, which 
takes the place of the cornea {phthisis cornece). The distinction be- 
tween applanatio and phthisis of the cornea is as follows : In the 
former the cornea is still present, although it is in part cicatricial, and 

* From avvix^iv, to connect. The term lencoma adhiBrens (from AeuKiis, white) 
is also employed to denote a cicatrix of the cornea with anterior synechia. 



DISEASES OF THE CORNEA. 151 

thus as a whole is flattened. In the latter, on the other hand, nothing 
of the cornea is left except a very narrow marginal rim, which gener- 
ally withstands the destructive process of ulceration. The flat scar 
which takes the place of the cornea is, in this case, the cicatrized iris. 

The healing of a prolapse of the iris with the formation of a fiat 
cicatrix must be regarded, even though the latter is opaque, as a com- 
paratively favorable outcome of a large corneal perforation. Such an 
eye, of course, is seriously impaired as regards its function, but yet, 
after the process has run its course, it remains in a state of quiescence, 
and generally causes its owner no further trouble. The case is differ- 
ent when healing takes place with the formation of an ectatic cicatrix. 
This occurs in the following manner : The prolapsed iris becomes cov- 
ered with cicatricial tissue, but this is not strong enough to effect the 
flattening of the prolapse. Hence the latter becomes consolidated in 
its original form as a protrusion, and is converted into an ectatic cica- 
trix with inclusion of the iris {staphyloma cornece). A large-sized per- 
foration opening and restlessness on the part of the patient favor the 
formation of such an ectasis. Whenever a prolapse of the iris has be- 
come so extensive that it is constricted by the margin of the perforation, 
and hence has acquired a mushroom shape, the formation of a flat cica- 
trix, without artificial aid, becomes altogether impossible. 

If the perforation in the cornea is not in front of the iris, but lies 
in the region of the pujyil, it can not be covered by the iris. Its occlu- 
sion in this instance takes place more slowly by an outgrowth of new- 
formed tissue (cicatricial tissue) from the margins of the opening, until 
the opening is filled up. In such a case the anterior chamber remains 
absent for a somewhat longer time, and meanwhile the lens is in con- 
tact with the posterior opening in the cornea. The lens may bear away 
permanent marks of this contact, most frequently in the form of a cir- 
cumscribed opacity at its anterior pole (anterior capsular cataract ; see 
§ 89). If during cicatrization the delicate membrane occluding the 
opening is repeatedly ruptured (which generally occurs from improper 
behavior on the part of the patient), the perforation may end by re- 
maining permanently open, and a. fistula of the cornea is formed. This 
appears under the guise of a small dark point, surrounded by whitish 
cicatricial tissue ; the anterior chamber is absent, the eye is soft. If 
the fistula of the cornea persists for a long time, the eye gradually per- 
ishes. The cornea flattens out, the eye grows softer and softer, and at 
length goes blind from detachment of the retina. On the other hand, 
as soon as the fistula closes up, an increase of tension is apt to set m, 
that may lead to a renewed rupture of the occluding substance, which 
is still but slightly resistant. An alternation of this sort between an 
open fistula with softness of the eyeball, gradual closure of the fistula, 
and a consequent steady increase of pressure until the cicatrix ruptures 
anew, may be repeated for a long time, until finally a severe inflanima- 



152 DISEASES OF THE EYE. 

tion occurs, which leads to the atrophy of the eye, and thus puts an 
end to the process. 

Other bad consequences of perforation of the cornea, which are 
sometimes observed, are : 

(a) Luxation of the Lens. — After the escape of the aqueous humor, 
the lens, to reach the cornea, must be pushed forward through the entire 
depth of the anterior chamber (2.5 millimetres), a movement associated 
with a considerable degree of stretching of the zonula of Zinn. If the 
forward movement takes place very suddenly, or if the fibers of the 
zonula have been rendered fragile by disease, the zonula ruptures. In 
consequence the lens may become tilted, or, if the perforation is large 
enough, may even be expelled from the eye. 

(J) Litra-ocular hcemorrhages are the result of the rapid diminu- 
tion in tension, by virtue of which an increased quantity of blood flows 
into the vessels of the interior of the eye, which have been thus sud- 
denly relieved of external pressure, and causes their rupture. Haem- 
orrhage takes place if the perforation occurs very suddenly, or if the 
eye beforehand was under an abnormally high tension. The latter is 
the case in glaucomatous and staphylomatous eyes, in which, further- 
more, there is generally also a degeneration of the vessels associated 
with an increased fragility of their walls. The haemorrhage may be so 
great that the entire contents of the eyeball are extruded by reason of 
it ; nay, more, the patient may almost be in danger of bleeding to 
death. 

(c) Suppuration starting from the cornea may be carried over into 
the deeper parts of the eye and lead to the destruction of the latter 
by purulent irido-cyclitis, or even by panophthalmitis. This occurs 
mainly in the case of extensive destruction of the cornea, especially if, 
at the same time, the suppuration is of a particularly virulent character, 
as in acute blennorrhoea or in ulcus serpens. 

The Clearing of Corneal Cicatrices. — After a long time has elapsed — 
months or years, that is — the cicatrix left by an ulcer appears less large 
and less opaque than it was directly after the healing of the ulcer was 
completed ; the cicatrix has partially " cleared up." In this way quite 
small cicatrices may become altogether invisible. The extent to which 
clearing takes place depends principally upon two circumstances : upon 
the thickness of the cicatricial tissue and upon the age of the indi- 
vidual. The deeper the cicatrix penetrates into the cornea, the less it 
clears up ; perforating cicatrices of the cornea, if they are ever so 
small, remain permanently opaque. (A fine example of this is afforded 
by the punctures which the discission needle makes, and which remain 
visible as gray points upon the cornea all during life.) The age of the 
individual influences the process of clearing, in that the latter makes 
greater advances the younger the patient is. For this reason cicatrices 
after blennorrhoea neonatorum often clear up in a wonderful way. 



DISEASES OF THE COENBA. I53 

34. Etiology.— With reference to their etiology, all inflammations 
of the cornea may be divided into two great groups : primary and sec- 
ondary keratitides. By the former, we understand those which have 
their starting point in the cornea itself ; by the latter, on the contrary, 
those which have passed over to the cornea from other structures, and 
most frequently from the conjunctiva. This distinction, true with re- 
gard to keratitis in general, is especially so with respect to ulcers of the 
cornea. 

Primary ulcers of the cornea most frequently owe their develop- 
ment to traumatism. Under this head belong not only injuries in the 
narrower sense of the word, but also a lesion of the cornea by means 
of small foreign bodies, by faultily placed cilia, by papillary growths 
on the free border of the lids, etc. Primary ulcers, furthermore, de- 
velop after the separation of eschars produced by burns or the action 
of caustics. Other ulcers are dependent upon a disturbance in the 
nutrition of the cornea, as the ulcers in eyes with absolute glaucoma 
where the cornea has become insensitive, or ulcers which develop in old 
cicatrices of the cornea (atheromatous ulcers). 

Secondary ulcers are the results of an affection of the conjunctiva. 
All inflammations of the conjunctiva may be complicated with inflam- 
mations of the cornea ; and in severe inflammations of the conjunctiva, 
as in acute blennorrhoea and diphtheria, this is quite the rule. 

In accordance with our present views regarding suppuration we 
must expect to find that in the majority of cases the direct cause of 
the formation of ulcers in the cornea is constituted by the entrance of 
micro-organisms into the corneal tissues. We may have to do in this 
case either with specific organisms, as in the case of acute blennorrhoea, 
diphtheria, etc., or with the ordinary pus cocci. The latter are always 
found in the secretion of a conjunctiva affected with catarrh. If, now, 
owing to slight traumatism, to detachment of the epithelium by the 
formation of a vesicle (in herpes corneas), or to any other cause, the 
protective epithelial covering of the cornea is injured at some spot, the 
door is opened for the entrance of cocci into the tissue of the cornea. 
In people of the working class ulcers of the cornea occur much more 
frequently than among the well-to-do classes, because they very often 
suffer from neglected chronic catarrhs, and at the same time very fre- 
quently render themselves liable to injuries of the cornea. 

Treatment. — Ulcers of the cornea are very amenable to proper and 
energetic treatment. They hence in general afford a favorable prog- 
nosis if they come under treatment early ; in the great majority of 
cases it is possible to put a stop to their progress, and produce regular 
cicatrization. The treatment varies according to the stage in which the 
ulcer comes under treatment. 

(«) Recent ulcers that are still foul (progressive) require, most of 
all, the consideration of the causal indication. In traumatic ulcers 



154: DISEASES OF THE EYE. 

any foreign bodies that are.still present must in every case be removed. 
Cilia which are directed against the cornea must be epilated ; papillo- 
mata of the edges of the lids, when causing trouble in the cornea, must 
be removed. In the numerous cases in which the ulcer of the cornea 
is caused by a conjunctival lesion, the treatment of the latter forms, as 
a rule, the most important part of our therapeutics, and under it, 
moreover, the ulcer advances toward recovery. Hence, in corneal 
ulcers resulting from catarrh, trachoma, or acute blennorrhoea of the 
conjunctiva, we mnst by no means desist from cauterization of the 
latter, if it is required by the conjunctival trouble. The only precau- 
tion that must be observed is that the caustics applied should not 
come into contact with the cornea itself — a contingency which can be 
avoided by carefully washing off from the conjunctiva any excess that 
may be present. Furthermore, we should cauterize with the silver solu- 
tion only, and not with the copper stick, which is too irritating, and still 
less with the acetate of lead, which might lead to the formation of in- 
crustations of lead upon the cornea. Moreover, as long as progressive 
ulcers are present in the cornea, no irritating collyria, such as the col- 
lyrium adstriugens luteum and the like, should be instilled, as they 
would then come into contact with the cornea. 

The indicatio morbi requires in most cases the application of a 
bandage. Bandages are distinguished into protective bandages and 
pressure bandages, according as they are applied lightly or firmly. In 
recent ulcers a simple protective handage is sufficient. The object of 
this is to keep the lids closed and at rest without exerting any pres- 
sure upon the eyeball. The immobilization of the lids acts chiefly to 
prevent the floor of the ulcer from being swept by the lids with every 
movement of winking, which would give rise to constant irritation of 
the ulcer, and also to pain through contact with the nerve fibers lying 
exposed in it. Hence the pain is sometimes cut short at once by the 
application of a proper bandage. The bandage acts also to protect the 
ulcer from dust. The dust which is always falling upon the cornea is 
continually carried off by the movements of the lids ; but in the de- 
pression which constitutes the ulcer it is not reached by the lids as 
they sweep over it ; it consequently remains lying where it is, and may 
infect the ulcer. The bandage, as a rule, is to be kept on until the 
ulcer gets to be clean and becomes lined with an epithelial covering 
which protects the cornea against exterior influences. When the floor 
of the ulcer is thinned and shows a tendency to bulge, the use of the 
bandage must be kept up until the freshly formed cicatrix is sufficiently 
strong to offer resistance to the intra-ocnlar pressure. 

A contraindication against the bandage is furnished by a profuse 
secretion, because the latter would be retained in the conjunctival sac 
by the closure of the lids, and would remain in constant contact with 
the ulcer. For this reason, in ulcers resulting from conjunctivitis the 



DISEASES OF THE CORNEA. 15 5 

bandage must be very often dispensed with. In quite small children, 
also, the bandage is generally useless, since it soon gets displaced ; and 
a badly applied bandage is more hurtful than any exposure of the eye 
could be. 

Next to the bandage atropine plays the most important part in the 
treatment of ulcers. It combats the inflammation of the iris, hence 
diminishes the general state of irritation, and so reacts favorably upon 
the ulcer itself. It must be instilled as often as is necessary, in order 
to keep the pupil steadily dilated. With these two remedies alone — 
the bandage and atropine — we attain our object in light cases. For 
those ulcers, however, which from the purulent hue or from the strong 
infiltration of their surrounding parts show a rapidly progressive char- 
acter, we must employ still other remedies. These are moist warm 
compresses, iodoform, subconjunctival injections, the actual cautery, 
and paracentesis of the anterior chamber. 

Moist warm compresses are made by taking a very light linen cloth 
folded several times, which simply covers the closed eye without press- 
ing upon it by its weight. Before being applied this is dipped in hot 
water and then well wrung out; and it must be changed frequently in 
order to be constantly warm. The warm compresses are applied every 
day for an hour or more, and the dressing must be left off each time 
for the same period. 

Very finely powdered iodoform may be sprinkled upon the ulcer 
itself. 

Stiiconjunctival injections of a l-to-1,000 sublimate solution may 
be also made beneath the bulbar conjunctiva. 

If in spite of these remedies the ulcer is evidently spreading, we 
must proceed to the operation of cauterizing the ulcer by means of the 
actual cautery (Gayet). For this purpose we use a small sharp-pointed 
cautery iron, or the galvano-cautery loop, or Paquelin's thermo-cautery. 
AVith one of these instruments the ulcer is cauterized wherever it shows 
a gray coating. In the case of extensive ulcers it is not necessary to 
cauterize the entire ulcerating surface, but it is sufficient to destroy the 
most infiltrated portion of its margin, at which an advance of the ulcer- 
ative process is to be expected. In performing the cauterization we 
make the cornea insensitive by the repeated instillation of a five-per- 
cent solution of cocaine hydrochloride. 

Another potent remedy for combating rapidly spreading ulcers is 
paracentesis of the anterior chamber (for the method of its perform- 
ance see the section on Operations, § 154). People were led to do 
this operation by observing that ulcers after spontaneous perforation 
generally went on to rapid healing. In a similar manner, artificial per- 
foration—!, e., puncture of the cornea— performed early prevents the 
extension of the ulcer and its threatened rupture. Why should we not 
wait until the ulcer spontaneously perforates the cornea? Because in 



156 DISEASES OF THE BYE. 

the meantime the ulcer keeps enlarging superficially and thus would 
produce a more extensive opacity, and, furthermore, because after ulcer- 
ative perforation of the cornea a prolapse of the iris almost always 
develops, leading to the formation of an anterior synechia, while with 
a properly performed puncture this is not the case. 

If perforation is imminent, and we prefer not to bring it about 
artificially by puncture, we take care to have the patient kept quiet — a 
thing best done by making him lie in bed, in order that the perforation 
may take place slowly, and that as little as possible of the iris may be 
driven into the opening. 

(J) When perforation of the cornea has taken place treatment has 
to aim at the following objects : in the first place, that the iris shall 
not adhere to the cornea, or at least shall do so to the smallest possible 
extent ; in the second place, that a firm and fiat (not ectatic) cicatrix 
shall be formed. The two objects are attained as follows : 

1. If the perforation is small the iris does not prolapse into it, but 
simply becomes applied to its posterior orifice. In such cases, rest, a 
bandage, and atropine suffice for the treatment. There then remains 
only a punctiform adhesion of the iris to the corneal cicatrix, and this 
is often subsequently drawn out into a thin filament. In particularly 
favorable cases no anterior synechia at all may be produced ; for in- 
stance, if the iris, before it has become firmly adherent to the site 
of perforation, is pushed away from it again by the reaccumulating 
aqueous. 

3. If — in the case of a perforation of greater size — the iris has pro- 
lapsed, it should be excised. A replacement of the iris into the anterior 
chamber (reposition) is in most cases impossible of performance, and, 
even if it should succeed, would have no lasting results, since the iris 
would continually prolapse again. For the performance of excision we 
first make the cornea insensitive by means of cocaine. Then with a 
sharp-pointed instrument (conical sound) we separate on all sides the 
adhesions of the prolapse to the perforation opening, draw the iris as 
far as possible out of the wound with the forceps, and snip it off close 
to the cornea (Leber). If the operation has been successful, the iris 
ought no longer to be attached anywhere to the margin of the aper- 
ture ; on the contrary, there should be a coloboma of the iris with free 
pillars, as after a regular iridectomy. In this way we obtain a firm 
cicatrix without inclusion of the iris. 

The performance of excision is possible only in recent prolapses 
(prolapses a few days old), as afterward the prolapsed iris becomes 
so solidly adherent to the margins of the perforation that the separation 
of the iris from the latter is no longer feasible. Similarly it is not to 
be recommended in the case of a very large perforation. In these two 
cases — i. e., 

3. In old or very extensive prolapses of the iris we abstain from re- 



DISEASES OP THE CORNEA. I57 

leasing the iris from the cornea ; we confine ourselves to the attempt 
to transform the prolapse into a firm and flat cicatrix. In many cases 
a pressure bandage applied for a long time accomplishes this end. If 
we can not attain our object in this way, as is particularly the case 
when the prolapse is constricted at its base like a mushroom, we must 
produce flattening of the prolapse by repeatedly puncturing it or by 
excising a small portion. In the case of a very bulging total prolapse 
of the iris, it is advisable to split it transversely, and then, after open- 
ing the anterior capsule, to expel the lens. If there is a remnant of 
sound cornea left broad enough for the performance of an iridectomy, 
this operation is an excellent means for securing the formation of a 
flat cicatrix. 

4. In keratocele, the maintenance of rest, the application of a band- 
age, and ultimately the puncture of the protruding vesicle, are em- 
ployed. 

5. In fistula of the cornea, in order to effect its closure, everything 
must be avoided that might temporarily increase the ocular tension, and 
thus force the fistula open again just as it is closing. Tor this pur- 
pose we order rest in bed, with the application of a light bandage to 
both eyes, while at the same time we instill a miotic (eserine or pilo- 
carpine, see § 04) in order to diminish the pressure in the anterior 
chamber. An iridectomy has a very good effect, but this can be per- 
formed only when the anterior chamber has been, at least to some ex- 
tent, restored. If these measures fail, we must remove the cicatricial 
margins of the fistula either by excising or by cauterizing them (with 
a blunt galvano-cautery or thermo-cautery point) so as to fill the fistula 
up with new, firm scar tissue. If, however, we are going to perform cau- 
terization, there must be some remnant, even though a shallow one, of 
the anterior chamber present, as otherwise we should singe the anterior 
surface of the lens. 

(c) The treatment of ulcers in the regressive period, or period of 
cicatrization, should aim at filling the loss of substance completely 
with a resistant cicatrix, and at rendering the latter as transparent as 
possible. For the attainment of both objects irritants are employed. 
AYe begin cautiously with the weaker remedies, passing gradually, if 
these are well borne, to the stronger ones. One of the mildest of 
irritants is powdered calomel ; more energetic is the action of the 
yellow-precipitate ointment (from one to four per cent), the collyrium 
adstringeus luteum,* and tinctura opii crocata.f In applying the 
yellow-precipitate ointment, we insert it into the conjunctival sac 

[* See p. 33.] 

[f The tiuctura opii crocata of the Austrian Pharmaoopceia is made by extract- 
ing 10 parts of salfron with 100 parts of aqua cinnamomi aquosa (cinnamon-water 
containing 5 per cent of alcohol) and mixing the solution thus obtained with opium 
in the proportion of 10 parts of the former to 1 part of the latter. — D.] 



168 DISEASES OP THE BYE. 

with a brush or glass rod, and then rub it about with the upper lid 
so as to perform a sort of massage upon the clouded cornea. Another 
irritant remedy that is recommended is nebulization — ^that is, the ap- 
plication of hot vapor (of water either alone or with the addition of 
irritant iiuids) to the cornea by means of an atomizer, such as is em- 
ployed for inhalation. It is advisable to continue the application of 
these irritants for a long time in order to secure the greatest possible 
clearing up of the cornea, but in so doing the remedies must be changed 
from time to time, as otherwise the eye gets accustomed to them and 
they lose their efficacy. 

Ulcers of the cornea are among the most frequent affections of the eyes, and 
special significance attaches to them because the opacities that they leave very 
often impair the sight. Ulcers of the cornea, if we except those resulting from 
conjunctivitis eczematosa, are found much more frequently in adults, and espe- 
cially in elderly people, than in children. It seems that in the later years of 
life the cornea is less well nourished, and is hence more disposed to disintegrate 
than in youth. 

The physician who is called to a patient with an ulcer of the cornea must, 
after examining the eye, have acquainted himself not only with the diagnosis 
but also the prognosis; he must tell the patient beforehand to what extent his 
sight will suffer permanent impairment, in order that such impaii-meot may not 
afterward be charged against the medical treatment. The prognosis for vision 
depends upon the situation, the extent, and the density of the opacity which 
the ulcer has left behind it. Small opacities, even when dense, are generally 
less injurious to vision than those which are less dense but extensive (§ 45). 
It is hence less serious for an ulcer to extend into the depth of the tissues than 
upon the surface. If an ulcer is progressing in the direction of the center of 
the cornea, every millimetre of advance causes additional injury to the vision, 
while an extension toward the corneal margin is almost a matter of indifference. 
No further disintegration is to be apprehended at those portions of the margin 
of the ulcer to which vessels have already penetrated, and so, too, a portion of 
the cornea, covered by pannus, is protected against suppuration in acute blen- 
norrhoea. In every instance the ulcer is arrested at the limbus, as it never makes 
its way into this or into the adjacent sclera. The only exception to this is 
formed by those ulcers which not infrequently develop from the nodules of 
conjunctivitis eczematosa situated in the limbus. Even extensive suppuration 
of the cornea, as in acute blennorrhoea, ulcus serpens, etc., always leaves a 
narrow rim of cornea intact, which, to be sure, is often not of sufficient size to 
render possible an iridectomy for the restoration of vision. 

Corneal ulcers occur under many various forms, some of which are well . 
characterized, partly by their etiology, partly by their aspect and course. These 
may be enumerated as follows : 

1. In conjunctkitis eczematosa, as well as in conjvveti»itis ex acne rosarea, we 
find small, superficial, generally marginal ulcers, which, as a rule, get well 
rapidly. There are, however, cases of conjunctivitis eczematosa in which the 
ulcers, without spreading along the surface, keep on steadily penetrating deeper 
and deeper until abrupt crater-shaped losses of substance are produced which 
speedily perforate the cornea. These ulcers, too, are commonly situated at the 



DISEASES OF THE CORNEA. I59 

margin of the cornea, and hence leave behind tliose peripheral incarcerations of 
the iris with marked displacement of the pupil that are characteristic of a con- 
junctivitis eczematosa which has run its course. 

3. The 'caseular fasciculus (keratitis fascicularis) is likewise observed in con- 
junctivitis eczematosa, and is produced by an ulcer making its way from the 
margin of the cornea farther and farther into the latter, and trailing after it a 
leash of vessels from the limbus (page 94). 

3. Catarrhal ulcers are cliaracterized by their crescentic shape, as well as by 
their position near the corneal margin, and concentric with it. 

4. In pannus trachomatosus small ulcers frequently occur, which develop 
from the infiltration at the margin of the pannus. Sometimes along the margin 
of the pannus a whole series of such ulcers is found, which also may coalesce 
into one large crescentic ulcer. Other ulcers develop in the midst of the pannus 
in spots where the infiltration penetrates more deeply into the cornea and leads 
to ulcerative disintegration. 

5. The central, non-irritative ulcer occurring in trachoma develops generally 
in the center of the cornea. It is distinguished by the abKence of accompany- 
ing symptoms of irritation, so that often the disturbance of vision is the only 
thing that calls the patient's attention to his trouble. Objectively, the ulcer is 
distinguished by the fact that even during the progressive period it is but very 
slightly clouded, so that it scarcely gives any evidence of its presence, except 
the loss of substance that it produces; it may therefore be very easily over- 
looked if we do not examine the cornea by carefully testing its reflex. It has a 
tendency to fill up incompletely with cicatricial tissue, so that a central facet 
remains which causes very great deterioration of sight by the production of ir- 
regular astigmatism. 

6. Ulcers in acute hlennorrTuea anA in diphtheria of the conjunctira generallj 
spread rapidly, and often lead to destruction of the entire cornea, or even to 
panophthalmitis. 

7. Traumatic ulcers of the cornea are, as a rule, small and superficial, and 
occur for the most part in elderly people. They are located in the zone of the 
cornea that lies in the palpebral fissure ; the upper third of the cornea, which is 
covered by the upper lid, therefore generally is exempt from them. But be- 
sides these ulcers, which run a rapid course and are benign, there also occurs — 
and usually after inconsiderable injuries— the dangerous sort known as ulcus 
serpens (see § 35). 

For the ulcers which develop as a result of desiccation of the cornea, see 
keratitis e lagophthalmo (§ 37). 

8. Small marginal ulcers of the cornea occur frequently in elderly people, 
especially of the male sex, without any conjunctival lesion or external trauma- 
tism being discoverable as their cause. They develop with pretty violent com- 
plications, but are scarcely of the size of a pin's head, and heal rapidly without 
penetrating deeply. They are particularly troublesome from the fact that they 
are prone to recur, so that many people have to go through with attacks of this 
kind of keratitis one or more times every year. The uratic diathesis appears to 
be a frequent cause of these ulcers, and general treatment directed against this 
diathesis and consisting of the proper dietetic regulations or the use of mineral 
waters often puts an end to the recurrence of the ulceration. 

9. Herpes comew febrilis (rarely also herpes cornece zoster, see § 43) may give 
rise to ulcers formed from the ruptured herpetic vesicles. These have the prop- 



160 



DISEASES OP THE EYE. 



erty of not penetrating deeply, but of being very prone to spread superficially. 
This superficial extension may take place in two ways: either the ulcer extends 
in all directions uniformly, in which case we have a large but quite superficial 
loss of substance everywhere surrounded by a narrow, sharp, usually festooned, 
gray, and infiltrated margin, which pushes its way farther every day (Pig. 48) ; 
or extension takes place in certain directions only. In the latter case, from the 
loss of substance, which originally is small, gray striae extend in one or more 
directions into the transparent cornea, and grow constantly longer, at the same 
time becoming forked, and also sending out lateral branches. Thus there is 
produced in the cornea a very pretty gray figure which is branched like a tree, 
and often bears nodular swellings at the extremities of its branches — keratitis 
dendritica (Emmert). This branched infiltrate breaks down into an ulcer having 
the form of a deep, branched furrow, with gray margins inclosing it (Fig. 49). 
Then this ulcer becomes clean and heals, leaving behind it an opacity, whose 




Fig. 48.— Large but quite Sd- 
PKRPiciAL Ulcer follow- 
ing Herpes Febrilis. The 
central gray ring corre- 
sponds to an earlier stage 
of the ulcer, which since 
then has advanced nearly 
to the margin of the cornea. 




Fig. 49. — Keratitis Dendri- 
tica. To the left of the 
large branched ulcer lies a 
group of delicate minute 
maculae, representlng_ the 
remains of the herpetic ef- 
florescences. 




Fig. 50.— Keratitis Stella- 
TA. The whole inner half 
of the cornea is moderately 
clouded and in it are four 
large and two very small 
ulcers, showing a stellate 
branching. 



branched form allows us to recognize, even some time afterward, the nature of 
the antecedent affection. 

In many cases of herpes, instead of a single large ulcer, numerous minute 
ulcers develop which are star-shaped and provided with short processes (kera- 
titis stellata (Fig. 50). 

All these forms of keratitis are characterized by their long duration (one to 
three months). 

10. Ulcus rodena (Mooren). A superficial ulcer develops from the margin of 
the cornea (usually the upper margin) with marked inflammatory complications. 
Prom the sound portion of the cornea it is limited by a gray, clouded margin, 
which is evidently undermined. This latter symptom is characteristic of ulcus 
rodens. After a short time the ulcer begins to grow clean and to cicatrize, be- 
coming covered with vessels from the limbus. Just when one supposes the 
process to be nearing complete recovery, a relapse sets in with a return of the 
symptoms of irritation, and in this the ulcer pushes its way forward some- 
what farther in the cornea. So the disease goes on with discontinuous attacks 
and intervening remissions, until the ulcer has covered the entire cornea. The 
latter is thus everywhere deprived of its superficial layers, and hence remains 
permanently clouded throughout its entire extent, so that vision is very greatly 
diminished. Perforation of the cornea in this affection has never been ob- 
served. This rare disease attacks elderly people, and not infrequently invades 
both cornesB either simultaneously or in succession. It was regarded as incur- 



DISEASES OF THE CORNEA. 



161 




Fig 51 —Keratitis Margi- 

^A^,IS SlIPERFICIALIS At 

the inner margin of the 
cornea is a pseudo-ptery- 
gium. 



able as long as surgeons were unacquainted with the cauterization of the cornea 
by means of the actual cautery. If, however, we destroy the margin of the 
ulcer by this means, the ulcer itself is sure to be cured. 

11. Keratitis marginctUs superjicialis is another rare disease, found in persons 
in middle life. A quite superficial ulceration spreads over the cornea, starting 
from its margin. It does not, however, start from 

all parts of the margin at the same time, nor does it 
advance uniformly. Consequently the ulcerated mar- 
ginal zone of the cornea is demarcated from the trans- 
parent central portion by a sinuous border formed by 
a fine gray line (Pig. 51). This variety of keratitis 
drags on for a long time — sometimes for years — 
periods of intermission alternating with relapses, 
which are associated with moderate symptoms of irri- 
tation. It is distinguished from ulcus rodcns in that 
the ulcer is extremely shallow, and hence the cornea 
within its limits shows only a very faint and grayish 
opacity. Moreover, the edge of the ulcer, scarcely visible in any case, is not 
undermined. The ulceration never reaches the center of the cornea, so that 
the extremely faint opacities that remain do not interfere with sight. Kera- 
titis marginalis superficialis often gives rise to a drawing of the conjunctiva up 
over the cornea in the form of a pseudo-pterygium (see page 116). 

The vascular fasciculus, keratitis dendritica, ulcus rodens, and keratitis mar- 
ginalis superficialis have the common trait of creeping along slowly in the cor- 
nea, for which reason they are also designated by the name of serpiginous ulcers 
of the cornea. 

12. Atheromatous ulcers develop in old cicatrices of the cornea when the 
latter have undergone degeneration through the deposition of lime or colloid 
masses or when they are exposed to mechanical injuries (as, for example, when 
at the apex of a corneal staphyloma). These ulcers torment the patient by the 
frequency of their recurrence and the associated symptoms of irritation ; they 
may also produce perforation of the cornea, and through this panophthalmitis. 

13. In the eyes which are rendered blind by glaucoma ahsolutum, purulent 
ulcers, usually under tlie form of ulcus serpens, may develop. These are ordi- 
narily associated with considerable hypopyon, and frequently terminate either 
in perforation of the cornea with resultant hemorrhages from the eyeball or in 
panophthalmitis. Like atheromatous ulcers, they aie caused by insutHcient 
nutrition and innervation of the cornea, an insufficiency already made apparent 
from the insensitiveness of the latter. With both varieties of ulcers, the enu- 
cleation of the blinded eye is sometimes the only remedy that permanently re- 
lieves the patient of the repeatedly recurring tormenting ulceration. 

The treatment of corneal ulcers has very recently made great progress, 
chiefly because of the introduction of cauterization by means of the actual cau- 
tery, which we owe principally to Gayet ; for those very purulent and infiltrated, 
rapidly progressive ulcers that we hitherto were often powerless to oppose are 
just the ones that are usually arrested at once by this means. The application 
of the cautery is painless when cocaine is employed, and does not, as might be 
supposed, cause any marked irritation of the eye. On the contrary, after its 
application, the pain often ceases instantly, while the other symptoms of irri- 
tation abate. In private practice, when one has no other means to resort to, 
11 



162 DISEASES OF THE EYE. 

the head of a probe or of a knitting needle, heated red-hot, may be employed 
for cauterization. The chief thing is to make the cauterization extensive 
enough. Perforation of the thinned floor of the ulcer can, with care, be easily 
avoided ; should it occur, however, it lias no bad results beyond what the per- 
foration itself gives rise to, since the hot point is cooled at once by the out- 
pouring aqueous humor. An opacity remains permanently at the cauterized 
spot; but since we only cauterize such places as would otherwise go on to puru- 
lent disintegration, the final opacity is not greater than it would have been in 
any case. 

Among antiseptics, iodoform dusted in the form of a fine powder on the 
diseased spot is of most service. From other antiseptic remedies I have seen 
no special results accrue, at least when applied externally. However, sublimate 
under the form of auhconjunetwal injections has been repeatedly employed in 
corneal ulcers (Reymond, Darier). After the eye has been cocainized, a few 
minims of a l-to-1,000 sublimate solution (to which cocaine may also be added) 
are injected beneath the bulbar conjunctiva, not too close to the limbus. The 
injection is followed by pain as well as by marked congestion and swelling of the 
conjunctiva, the latter symptoms not usually disappearing until after several 
days. The injections are made at intervals of several days. Besides being em- 
ployed in suppurative processes in the cornea, they are used in parenchymatous 
keratitis, scleritis, iritis, and irido-cyclitis ; likewise also in chorioiditis and reti- 
nitis. Moreover, tile attempt has been made to apply them in purulent infection 
from wounds of the eyeball, whether consequent upon injury or upon operation. 
Subconjunctival injections of sublimate are mainly of service in progressive 
corneal ulcers ; in other sorts of cases the results obtained from them are rather 
uncertain. 

Eserine is employed by many in the place of atropine in purulent ulcers of 
the cornea. It seems to me, however, to have no action upon the corneal pro- 
cess itself, and, on the other hand, enhances the condition of irritation of the 
iris and leads to the formation of numerous posterior synechiee. It is more in- 
dicated in those cases in which there exists near the margin of the cornea a 
small perforation, to the posterior aperture of which the iris has become ap- 
plied after the escape of the aqueous humor. Here we may hope to produce, 
by means of eserine, so powerful a contraction of the sphincter iridis that the 
iris will be drawn away from the aperture, and thus the formation of an anterior 
synechia be prevented. On the other hand, if the site of perforation should be 
nearer the center of the cornea, so that the pupillary portion of the iris is ap- 
plied to it, we must employ atropine in order to draw the iris away from the 
opening. If, however, the iris has already fallen through the opening in the 
cornea, so that a real prolapse exists, neither atropine nor eserine, as a rule is 
able to release the iris from the wound and return it to the anterior chamber. 
In this case excision of the prolapse, as recommended by Leber, is the only 
remedy. 

Fistulm of the cvrnea mainly occur as a sequel of perforations that lie opposite 
the pupillary margin of the iris, so that the iris can not cover the opening com- 
pletely, but is simply attached by its pupillary border to the cicatricial tissue 
closing the gap. In this case, the iris, by continually dragging upon the cica- 
tricial tissue, prevents it from becoming consolidated. "While, then, such corneal 
fistulas do not as a rule present wide canals lined with epithelium, and while, 
on the contrary, we find the perforation opening filled with scar tissue, this 



DISEASES OF THE COENBA. Ig3 

tissue is not dense, but is permeated by fissures through which the aqueous 
keeps oozing until it reaches the exterior surface of the cornea (Czermak). 
The origin of other flstulte is that the prolapsed iris splits apart under the 
strain produced by the pressure of the aqueous, and the opening thus formed 
never closes solidly again. Lastly, in very extensive prolapses of the iris, it 
may happen that in the process of cicatrization a fistula is left at the spot cor- 
responding to the pupil. 

It is usually hard to effect firm union in fistulse of the cornea. In some 
cases I have ultimately obtained success by sewing over the fistula a fiap taken 
from the adjacent conjunctiva. The flap by growing fast to the surface of the 
scar, whose epithelium had previously been removed, closed the fistulous open- 
ing. Another procedure consists in excising by means of the corneal trephine 
the fistula, together with the cicatricial tissue surrounding it, and implanting in 
the opening an equally large piece of healthy cornea. 

5. Ulcus Serpens Cornem* 

35. Symptoms. — A recent ulcus serpens appears under the form 
of a grayish-white or yellowish disk, which occupies nearly the cen- 
ter of the cornea. The opacity of the disk is greater at its edges 
than in the center, and generally the edges themselves show a particu- 
larly well-marked gray or yellow opacity in one special direction. The 
disk is surrounded by a delicate gray area, and frequently fine, radiat- 
ing, gray stris extend from the margin of the disk into the transpar- 
ent part of the cornea. The surface of the cornea over the disk is dot- 
ted, and often at the beginning is raised some distance above the level of 
the surrounding parts. Soon, however, this spot is seen to be de- 
pressed, although not with abruptly depressed edges, as in the case of 
an ulcer, but rather under the form of a shallow dimpling. Moreover, 
the rest of the cornea that is not occupied by the serpent ulcer proper 
is less lustrous, being covered with a delicate uniform cloudiness. 
These changes in the cornea are always associated with a violent iritis. 
The aqueous humor is turbid, a hypopyon lies at the bottom of the 
anterior chamber, the iris is discolored and is fastened by posterior 
synechiee to the lens capsule. Corresponding to the severity of the 
inflammation is the violence of the irritative symptoms : slight oedema 
of the lids, intense injection of the conjunctival and ciliary vessels, 
photophobia, and pain, which latter often reach a very considerable 
height. Nevertheless there are also torpid cases, which are associated 
with very slight symptoms of irritation. 

The subsequent course consists in the enlargement, both super- 

* Synonymous terms for ulcus serpens corneEe (Saemisch) are hypopyon kera- 
titis (Roser) and abscess of the cornea. The latter name, used by the older authors, 
I myself employed to denote the affection in former editions of this text-book, but 
the name ought to be given up, since in ulcus serpens there is no actual abscess 
cavity in the cornea. 



164 DISEASES OF THE EYE. 

ficially and in depth, of the serpent ulcer. The superficial enlargement 
takes place chiefly in that direction in which the margin is marked 
by a specially dense opacity — an opacity which not infrequently looks 
like a yellow crescent placed upon the serpent ulcer. Inasmuch as the 
anterior lamella of the cornea within the region occupied by the ulcus 
serpens keep breaking down more and more, there is formed an exten- 
sive ulcer, the floor of which is coated with pus. Soon after this, gen- 
erally, those lamellse of the cornea which now form the base of the 
ulcer are also destroyed, so that an extensive perforation of the 
cornea is produced. The contents of the anterior chamber, consisting 
of aqueous humor and pus, are evacuated, and a large prolapse of the 
iris forms. 

While the ulcus serpens is going through with its process of devel- 
opment, the accompanying iritis keeps on increasing in the same pro- 
portion up to the time of perforation of the cornea ; the hypopyon, too, 
keeps growing until it tills the greater part of the anterior chamber, 
and the pupil is closed by an exudation membrane. 

After the perforation of the cornea has taken place the irritative 
symptoms generally abate and the suppuration may now come to a 
standstill. In other cases, however, the purulent disintegration of the 
cornea keeps on just the same, so that the latter is entirely destroyed, 
with the exception of a narrow marginal rim. Panophthalmitis may 
even result from the suppuration passing over into the deep parts. 

An ulcus serpens always leaves a very dense corneal cicatrix which 
can not be cleared up, and in which the iris is almost always incarcer- 
ated. Furthermore, in consequence of the iritis, there are usually left 
adhesions of the iris with the capsule (posterior synechias), and even a 
closure of the pupil by a membrane (occlusio pupillse). The corneal 
cicatrix itself is in favorable cases flat, in unfavorable cases ectatic, so 
that the ulcus serpens ends by forming a staphyloma. If panophthal- 
mitis has followed upon the ulcus serpens, a shriveling up of the eye 
(phthisis bulbi) takes place. 

The clinical picture which is characteristic of ulcus serpens and by 
which the diagnosis is made is only present in the beginning of the dis- 
ease. Its important features are the dislcUlce form and central situation of 
the opacity, the more pronounced opacity of the margin in comparison 
with the center, the character of the corneal surface, which, at the site 
of the ulcus serpens, shows only a shallow depression, and finally the 
early onset of hypopyon and iritis. 

1\\e prog7iosis of ulcus serpens is always serious, as, on account of 
the malignancy of its course, it belongs to the most dangerous of the 
diseases of the eye, and, if not checked early, it generally ends by pro- 
ducing blindness through an incurable opacity of the cornea. And 
even in the favorable cases, which either spontaneously or with the 
help of art come to a stop early, a dense, centrally situated opacity re- 



DISEASES OP THE CORNEA. 105 

mains, so that usually the sight can only be restored by the perform- 
ance of an operation (iridectomy). 

36. Etiology. — An ulcus serpens originates in infection of the cor- 
nea by organisms (the pneumococcus) which set up in it a purulent 
inflammation. Such infection presupposes two conditions : first, a le- 
sion of the corneal epithelium, which in the normal state protects the 
cornea against the entrance of micro-organisms ; and, second, the pres- 
ence of pyogenic organisms which find their way to the spot where the 
epithelium is wanting. Both of these conditions occur in many cases 
of injury of the cornea. The body which inflicts the injury may itself 
be the carrier of infection and inoculate the cornea with germs. Much 
more frequently the inJLiry, by producing a loss of substance in the 
epithelial covering, simply affords the opportunity for the entrance of 
infection, the infecting germs being furnished by the secretion con- 
tained in the conjunctival sac. The injuries which in this manner lead 
to the formation of ulcus serpens are, as a rule, very slight, consisting 
in a simple scaling off of the epithelium. Among such injuries, for 
example, is the scratching of the cornea with the finger nail, a thiug 
which children very often do to their mothers who are carrying them 
in their arms. A rough cloth, a leaf, or a branch grazing the cornea, 
and small foreign bodies, especially minute fragments of stone, which 
fly into the eye, likewise produce these superficial injuries. Even in 
those cases in which a typical ulcus serpens has appeared to originate 
spontaneously, it is probable that there has been an antecedent injury, 
since such slight injuries of the cornea as these are readily overlooked 
by the patients. In exceptional cases severe perforating injuries, and in 
a similar way operation wounds, may also give rise to an ulcus serpens. 
Associated with the injury, as the second factor in the production of 
ulcus serpens, is the presence of a chronic lesion of the conjunctiva 
(catarrh or trachoma), or a blennorrhcEa of the lachrymal sac (present 
in about one third of the cases of serpent ulcer), by which the infecting 
secretion is furnished. 

Traumatic ulcus serpens attacks adults exclusively, and especially 
those belonging to the working class. These are more frequently ex- 
p^osed to injuries of all kinds, and, besides, more often suffer from 
neglected affections of the conjunctiva and lachrymal sac than do mem- 
bers of the well-to-do classes. Great heat favors the formation of ulcus 
serpens, which is hence much more frequent in the hot season than in 
winter. For this reason reapers are not infrequently affected with the 
disease, since in cutting the grain they scratch their eyes with its awns, 
and, besides, they do their work during the hottest days of the year. 
Stone masons also are particularly apt to be attacked by ulcus serpens. 

In ulcus serpens resulting from acute blennorrhcea and from diph- 
theria of the conjunctiva there is likewise without doubt a penetration 
of phlogogenic germs into the cornea from the conjunctiva. 



166 DISEASES OF THE EYE. 

Ulcus serpens also occurs in acute infectious diseases, such as small- 
pox, scarlet fever, measles, typhus, etc. The form that results from 
variola is most frequently observed. In this case it makes its appear- 
ance not at the height of the disease but in the stage of desiccation, 
and, in fact, sometimes even in patients who have already left their 
beds. These variolous ulcers are found in children as well as in adults, 
and not infrequently affect both eyes so that total blindness may be 
produced by them. 

Since the ulcus serpens in variola develops such a length of time 
after the stage of eruption, it obviously can not be regarded as a small- 
pox pustule that has been localized upon the cornea. Hence in this 
case as well as when occurring with other infectious diseases, it has 
been considered to be a metastatic affection. If the metastasis is sup- 
posed to occur in the way of embolism, we should have to assume, since 
the cornea itself is bloodless, that the embolus is arrested at some point 
in the marginal network of vessels surrounding the cornea, and that 
acting from this point it sets up the suppuration. But the clinical 
picture presented by ulcus serpens, which is a process that begins in 
the center of the cornea, does not agree with this view. Hence ob- 
servers are now inclined to the belief that the variolous ulcer, like other 
ulcers, is to be referred to infection from without. There is no lack 
of opportunity for such infection to take place, since the free border of 
the lids is a favorite seat for variolous pustules, which thus can come 
into direct contact with the cornea. 

Treatment. — In consideration of the rapid progress which an ulcus 
serpens usually makes, and which threatens the entire cornea with de- 
struction, a particularly prompt and energetic interference is required. 
The treatment is partly medicinal, partly operative. 

The medicinal treatment is the same as in purulent ulcers of the 
cornea — namely, the application of a bandage, atropine, iodoform, moist 
and warm compresses, and subconjunctival injections of sublimate. At 
the same time, any lesion of the conjunctiva or lachrymal sac that may 
happen to be present is to be suitably treated. This treatment is only 
adapted to the case of small recent ulcers without an excessively large 
hypopyon. It should be undertaken only under the condition that the 
disease is closely watched, so that in case the latter progresses in spite 
of it, we may immediately proceed to operative treatment. 

Operative treatment must be initiated without delay in all severe 
cases of ulcus serpens, but is also required in the lighter cases when 
they resist the mild treatment. It consists either in the cauterization of 
the ulcer by means of the actual cautery or in its incision according to 
the method of Saemisch. Gaiiterization is performed in the same wav 
as in the case of progressive ulcers of the cornea; special attention 
must be paid to the destruction of the progressive portion of the mar- 
gin. Cauterization has the advantage over incision of not causing a 



DISEASES OF THE CORNEA. 16Y 

perforation of the cornea, and hence of not giving rise to inclusion 
of the iris. It is suitable, however, only for those ulcers that have 
not yet undergone perforation, and in which the hypopyon is not ex- 
cessively large, for the latter is not removed from the eye by this 
method ; it can disappear from the anterior chamber only by resorption. 
Incision of the ulcus serpens (puncture by Saemisch's method, see the 
section on Operations, § 154), beside dividing freely the corneal lamellas, 
which are saturated with pus, also effects the evacuation of the hy- 
popyon ; it, however, entails the disadvantage of a frequently extensive 
incarceration of the iris. Incision is suitable for very extensive ulcers, 
for those in which perforation is imminent, and for those which are 
associated with a large hypopyon. We should not let the matter rest 
with a single performance of the incision, but must every day separate 
anew with a blunt instrument the edges of the wound, as they speedily 
reunite, and we must keep this up until the ulcer begins to grow clean. 
At the same time that this operative procedure is being performed, the 
medicinal treatment above mentioned must be continued. Perforation 
and prolapse of the iris, when once they have occurred, must be treated 
according to the plan that has been laid down for perforating ulcers 
(page 156). 

According to our present views, purulent inflammations everywhere are, 
with rare exceptions, to be referred to the presence of ScMzomycetes. In the 
special case of pamlent inflammation of the cornea, the presence of fungi has 
for a long time been a matter of demonstration, the principal organisms found 
being the staphylococcus, streptococcus, pneumobacillus (of Friedlander), and 
the pneumococcus (of Friinkel and Weichselbaum). The last named is the 
most frequent exciting cause of the typical ulcus serpens, which possibly owes 
its very peculiarities to the special properties of this germ (Uhthofi and Axen- 
feld). In rare cases mold fungi (Aspergillus fumigatus) have been found as 
the cause of suppurative keratitis. 

The micro-organisms, whose presence in the suppurating cornea has been 
demonstrated, are also without doubt the real exciting cause of the suppura- 
tion. Traumatism alone, without infection, does not give rise to suppuration. 
We may cut, scrape, crush, or, in short, injure in any way, or even cauterize 
the cornea of an animal without getting any purulent inflammation of it ; in 
every case simply a gray cloudiness develops, which generally disappears again 
quickly. But when, by repeatedly touching the conjunctiva with nitrate-of- 
silver solution, we have artificially produced a conjunctival catarrh, and in this 
way have given the opportunity for the production of infection, we then see 
purulent infiltration follow upon these same lesions of the cornea (Thilo.) What 
is true of the cornea of animals is also true of that of man. Provided we avoid 
infection by cleanliness and antiseptic measures, we can with impunity subject 
the cornea to operations both light and severe ; even crushing of the cornea, 
such as, for example, is often enough produced in the expression of a cataract, 
does not always by any means lead to suppuration. But if we undertake the 
same operation in the presence of a conjunctival catarrh or a suppuration of 
the lachrymal sac, we risk the loss of the eye from a purulent infection of the 
wound. 



168 



DISEASES OP THE EYE. 




In what way does infection of the cornea by pus germs lead to the develop- 
ment of a suppurative heratitis f We owe our knowledge in regard to these 
processes and the true explanation of them chiefly to the investigations of 
Leber, who made inoculations of various kinds of germs upon the corneffl of 
animals. The morbid processes that he observed to result from these inocu- 
lations he refers to the toxic eflect which the products of the tissue metamor- 
phosis of the cocci induce. He assumes that the chemical substances produced 
by the cocci exert upon the cell protoplasm an irritant action, when but slightly 
concentrated, and, when more concentrated, a paralyzing and ultimately fatal 
eflEect. When pus cocci are introduced into the cornea by inoculation they 
first increase in number within the corneal tissue. Then the cornea for a cer- 
tain distance about the colony of cocci dies, because the toxic substances ex- 
creted by the cocci are present within this area 
in a state of strong concentration. According- 
ly, the colony of cocci now lies in the center of 
the necrotic area (Fig. 52). In the meantime 
violent inflammatory symptoms have made their 
appearance in the eye. The toxic substances by 
diffusion have reached the margin of the cornea, 
and there cause dilatation of the vessels and in- 
creased permeability of the vessel walls, entail- 
ing as a necessary consequence increased diape- 
desis of the blood plasma. In addition to this 
diapedesis of serum an emigration of white 
blood corpuscles also takes place from the ves- 
sels. This is effected by active movements of 
tlie leucocytes, which, irritated by the toxic 
substances, emigrate toward the focus of inflam- 
mation (chemotaxis). This migration of thb leu- 
cocytes may be explained in the following man- 
ner: The degree of concentration of the toxic 
substances diminishes gradually from the spot 
where the irritation originates to the periphery. 
Hence, that side of the body of a leucocyte that 
is turned toward the starting point of the irritation is in contact with a more 
irritating fluid than is the side which is turned in the opposite direction. 
Hence the protoplasmic processes push out more on the former side than on 
the latter, and the whole cell consequently moves toward the source of irri- 
tation. The leucocytes, however, do not make their way into the necrotic 
district itself, the pus cells that are found there being such as have emigrated 
from the conjunctival sac. In fact, the leucocytes derived from the margin of 
the cornea are paralyzed at the border of the necrotic area owing to the great 
degree of concentration of the toxic substances at this spot. Thus it happens 
that a constantly increasing number of cells are arrested at the margin of the 
necrotic spot, and die there. In this way is produced the infiltration (or mi- 
gration) ring, which is apparent to the naked eye. Now leucocytes have the 
property of dissolving by a kind of digestive action tissues in which they are 
present in large quantities. They effect by this means the exfoliation of the 
necrotic area, and give rise to a delimiting suppuration. The inflammatory 
phenomena in the cornea, consequently, appear under the guise of a process 



Fig. 52.— Inoculation Keratitis. 
(After Leber.) Magnified 3x1. 

Surface section through a rabbit's 
cornea, into the center of which 
a dilute suspension of Staphylo- 
coccus aureus had been injected 
three days before. In the middle 
of the cornea is seen the mass of 

Eroliferating cocci, surrounded 
y a necrotic zone. This latter 
is bordered by a broad migra- 
tion ring, adjoining which below 
there is a second one, narrower 
and not complete. 



DISEASES OP THE CORNEA. 169 

having a definite purpose to subserve, the principal end and object of which 
are to eliminate the necrotic area, and with it the morbific agents that it con- 
tains. But beside this the pus corpuscles, as experiment has shown, have the 
additional property of directly inhibiting the growth of germs, so that they 
oppose the diffusion of those schizomycetes that may have chanced to grow out 
beyond the necrotic mass. 

Since the cornea is an organ which extends mainly in one plane, the migra- 
tion zone does not form a spherical shell, but a ring. Yet, according to Leber, 
migration is not wanting on the posterior surface of the cornea also. The way 
in which this occurs is, that first the endothelium of Descemet's membrane over 
the necrotic area becomes detached and a clot of fibrin is precipitated from the 
aqueous upon this portion of the posterior wall of the cornea. Then leucocytes 
migrate into the clot, so that soon a plug of pus can be seen on the posterior 
surface of the cornea at a point corresponding to the site of the inoculation. 
This pus, by sinking down to the bottom of the anterior chamber, forms the hy- 
popyon. 

Leber's experiments were all made upon animals, in which it is not possible 
to produce a morbid picture perfectly similar to the ulcus serpens in man. 
And, for reasons that will be readily comprehensible, anatomical researches on 
human eyes affected with ulcus serpens do not exhibit its early stages, whose 
anatomical character must be inferred from what is found to obtain in the more 
advanced cases. I have in my possession preparations made from nine cases of 
ulcus serpens (including four of Dr. Elschnig's), and from the concurrent testi- 
mony of these the course of the disease shapes itself as follows : An infiltrate 
forms in about the center of the cornea. This infiltrate is like that represented 
in Fig. 38, but is somewhat more superficially placed, and, on the other hand, 
is denser. The corneal lamellae placed over the infiltrate become necrotic, and 
then swell up and exfoliate. Thus, in place of the infiltrate there is formed a 
flat open ulcer, the floor of which consists of fibers of the cornea, that have 
been heaved up and are swollen to an almost homogeneous mass, and between 
which only a very few, sparsely scattered pus corpuscles are to be seen. It is 
only at the margins of the ulcer that the remains of the infiltrate can still be 
distinguished, and here it penetrates— appearing in cross section like a wedge 
—into" that portion of the cornea that still is sound (Fig. 53 C, a). This 
residue of infiltrate corresponds to the yellow, advancing border of the ulcus 
serpens; it keeps insinuating itself farther and farther along between the 
tamelljB of the cornea, so as first to lift up and then to detach the layers that 
overlie it. In many cases of ulcus serpens the infiltration of the margin soon 
disappears at some portion of its circumference, so that the ulcer advances in 
one direction only. This progressive portion of the ulcer's border then looks 
like a yellow crescent (Fig. 53 J, a) applied to the disk-shaped ulcer, which 
itself is often so little clouded that one can scarcely recognize it except by the 
shallow depression that it produces in the surface of the cornea. In this case 
wherever in the living eye the yellow margin is no longer visible anatomical 
dissection shows the wedge-shaped infiltrate to be absent (Fig. 58 C, I). At 
this point the epithelium passes over the edge of the ulcer and out upon its 
floor, covering the latter in an irregular uneven layer, often as far as the ad- 
vancing portion of the border. This fact explains why such ulcers give an 
almost mirrorlike reflex. It would, however, be erroneous to assume that the 
portions of the cornea that have once more become covered in this way with 



170 



DISEASES OP THE EYE. 
B 




Fig. 53.— Ulcus Serpens. A^ front view ; .B, cross sec- 
tion. Magnified 3.} X 1. C, cross section. Magnified 
20 X 1. 

In tliis, as in most of the cases of ulcus serpens that 
have been examined anatomically, the eye was af- 
fected with absolute glaucoma. The ulcer occupied 
about the center of the cornea ; its upper, advanc- 
ing border, a. was clearly recognizable as a .yellow 
crescent, while the lower border, being but slightly 
opaque, did not specially stand out against the sub- 
jacent masses of pus which lay in the anterior 
chamber and extended as low down as c. Farther 
below, between the cornea and the iris, is seen the 
hypopyon, the upper border of which (d) is convex. 
Owing to the glaucoma, the iris has, rather pecul- 
iarly, become adherent by its periphery to the cor- 
nea, e, posterior abscess in the cornea. 

ute to the production of perforation. Here 
takes place early, and these migrate toward 
their way mainly along the posterior surface 



epithelium have healed. Nature 
tries to cover every wound with 
epithelium as rapidly as possi- 
ble, in order to protect it from 
the outside world. In such a 
case it often happens that the 
epithelium covers masses of dy- 
ing tissue, and even masses of 
pus. So also in Fig. 53 0, we 
see at a how the epithelium has 
grown over the advancing por- 
tion of the border, which is on 
the very point of disintegration. 
Moreover, those lamellis of the 
cornea that lie directly beneath 
the epithelium and form the 
floor of the ulcer are no longer 
capable of surviving; they are 
swollen up, destitute of corneal 
corpuscles, and contain only a 
few pus cells. The deeper-lying 
lamellse are apparently normal ; 
but upon careful examination it 
is found that no corneal corpus- 
cles susceptible of staining can 
be distinguished in them, so 
that they also in large part are 
on the way to destruction. 
Hence it is that although in 
ulcus serpens the purulent infil- 
tration does not go very deep, 
nevertheless very extensive per- 
foration of the cornea occurs. 

The changes which simulta- 
neously take place at the poste- 
rior surface of the cornea contrib- 
an accumulation of pus corpuscles 
the inflammatory deposit, making 
of Descemet's membrane. They 



DISEASES OP THE CORNEA. 



171 



are derived from the vessels of the uvea, and chiefly from the vessels surround- 
ing the sinus of the anterior chamber ; and as proof of their origin, many of 
them contain small granules of pigment derived from the uvea. The pus cor- 
puscles congregate to form a mass of pus upon the posterior wall of the cornea ; 
they then penetrate into Descemet's membrane and ultimately into the cornea 
itself. In this latter, therefore, there is formed a sort of posterior abscess (Fig. 
53 G, e) at a point corresponding to the site of the ulcus serpens. Directly in 
front of this abscess lie those corneal lamellae which, as already mentioned, 
are destitute of corneal corpuscles and are undergoing dissolution ; and their 
necrosis in conjunction with the abscess gives rise to the perforation of the 
cornea. 

If we compare these observations with the results obtained in Leber's 
experiments upon rabbits, we must regard the posterior abscess and the 
wedge-shaped infiltration at the advancing margin as parts of the migration 
zone. 

The pus of the posterior abscess, which lies within the cornea itself, is in 
direct communication with the purulent masses that are applied to the posterior 
surface of the cornea. These latter form coherent lumps (c. Fig. 53 C), which 
sink to the bottom of the anterior chamber until they unite with the hypopyon 
{d, Fig. 53 C) present there. In the living eye these masses of pus upon the pos- 
terior surface of the cornea often render it impossible to make out precisely the 
limits of the ulcus serpens, inasmuch as the latter does not contrast sufficiently 
with the yellow background made by the pas (Fig. 53 A). 

The hypopyon has usually a border that in front view appears convex 
upward (Fig. 53 A, d). It is, moreover, agglutinated to the posterior surface 
of the cornea (Fig. 53 C, d), so that when we look into the anterior chamber 
from above we can see down between the hypopyon and the iris. 

The older authors were well acquainted with tliese appearances, but gave 
them a different interpretation. They regarded the thread of pus extending 
dovrn into the anterior chamber as a hypopyon situated in the cornea itself, 
assuming that the pus settled down between the corneal lamellae. They 
explained the flattened shape of the hypopyon and the convex curve of its 
upper border as being due to the contracted space occupied by the pus inclosed 
between the corneal lamellae. On account of the convexity of its upper border 
they compared the hypopyon to the lunula of the finger nail, and hence called 
it unguis or onyx (nedl). These expressions would therefore .denote a settling 
of pus down between the lamellae of the cornea — a phenomenon, however, that 
does not actually occur. 

The variety of keratitis produced by mold fungi Qceratomycosis aspergillina) 
presents even upon external examination a clinical picture differing from that 
of the ordinary ulcus serpens. There forms in the central portions of the cor- 
nea an infiltrate which later undergoes superficial disintegration, and is distin- 
guished by its peculiar, dry, crumbly surface. About this area a gray or yellow 
annular line of demarkation forms, which gradually deepens into a gutter and 
ultimately leads to the exfoliation of the inclosed portion of cornea, which in the 
meantime has become necrotic. The latter being thus detached en masse from 
the cornea, cicatrization of the resulting loss of substance ensues. Hypopyon 
is present, but the irritative symptoms are slight, and the whole course is very 
chronic. Examination of the sequestrum shows it to be permeated by a growth 
of the mycelium of the Aspergillus fumigatus. It is probable that, as a general 



172 DISEASES OF THE EYE. 

thing, this fungus is carried into the cornea by the foreign body that caused 
the original injury. 

A keratitis that has a certain resemblance to ulcus serpens consists in the 
development in the middle layers of the cornea of a gray, disk-shaped opacity, 
•which is sharply limited by a border of deeper gray from the transparent 
periphery of the cornea. In the center of the disk a small, more deeply 
clouded speck is commonly observed. The gray border of the disk may be 
made up of several concentric circular lines. This disk- shaped infiltrate never 
becomes yellow and never leads to disintegration of the cornea; only excep- 
tionally a small loss of substance develops over a circumscribed area. The 
irritative symptoms are mostly not very pronounced, and hypopyon is absent 
or but scanty. The course of the disease is a protracted one, as it takes one or 
more months for the eye to become free from congestion and for the infiltrate 
to be transformed into a corneal opacity. This latter is permanent. In the 
course of the disease it often happens that -scattered, superficial, or deep-seated 
blood-vessels develop which extend into the infiltrate. Cases of similar nature 
were described by the older ophthalmologists under the name of abseessus siccus, 
by which term they meant an abscess in which no suppuration had occurred. 
In reality it is likely that in these cases, as well as in ulcus serpens, infection 
of the cornea from without lies at the bottom of the trouble. In argument for 
this view it may be said that the central graj'er speck represents the point of 
entry of the bacteria and the gray marginal line the migration zone. The dis- 
tinction between this and ulcus serpens would consist in the fact that the 
inflammation does not advance to the point of supjDuration, and the reason 
for this may be that we have here to do with bacteria that give rise to a milder, 
non-suppurative form of inflammation. The way in which the infiltrate origi- 
nates is not known, since no history of injury is given by the patients, and usu- 
ally, too, there are no lesions of the conjunctival or lachrymal sac present. 
The disease has a certain resemblance to keratitis profunda (see § 43), in which 
likewise a deep-seated, gray, non- ulcerating infiltrate develops in the center of 
the cornea. But this is composed of gray strias and maculfe, and merges gradu- 
ally into the transparent cornea. The infiltrate here described, on the contrary, 
appears uniformly gray and only under a very high magnifying power can be 
resolved into extremely minute, well-defined, white, closely agglomerated 
points ; moreover, it is quite sharply separated from the healthy cornea by the 
gray circular line forming its border. 

The annular abscess of the cornea usually occurs after perforating injuries 
of the latter, and also after operations (especially cataract operations). No mat- 
ter where the corneal wound that gives rise to it is situated, it develops in the 
central portions of the cornea as a yellow ring which is concentric with the 
limbus and is separated from it by a slightly cloudy marginal zone, one to two 
millimetres broad. The ring itself has about the same width ; the central por- 
tions of the cornea inclosed by it are again less cloudy and simply gray, not 
yellow. In the next few days, however, the yellow coloration spreads over the 
entire cornea ; the latter disintegrates completely, and not infrequently panoph- 
thalmitis ensues. Here accordingly we have to deal with an afl'ection of the 
cornea of a peculiarly fulminating course, so that it is best to enucleate at once 
such an eye affected thus with annular abscess. 

The treatment of ulcus serpens had in general but little success to chronicle 
until Saemisch substituted the operation of incision for that of paracentesis, of 



DISEASES OF THE CORNEA. 173 

iridectomj', etc., previously in vogue. In performing the operation -we raust 
take care not to injure the lens and not to let the escape of aqueous take jslace 
too suddenly. The hypopyon is either evacuated spontaneously, especially if 
the patient makes pressure with his lids, or it can be grasped by means of a for- 
ceps introduced into the wound, and drawn out. For, in ulcus serpens, it is 
not thin and liquid, but of a tenacious, viscid consistence. In consequence of 
the diminution of pressure after the escape of the contents of the anterior cham- 
ber haemorrhages often take place from the iris, which, already hypersemic be- 
fore the operation, now becomes still more distended with blood. This is 
probably the cause of the violent pain which regularly follows upon the evacu- 
ation of the contents of the anterior chamber, although the incision itself is but 
little felt. After incising the ulcus serpens we always get an attachment of the 
iris to the cornea during healing, which, however, would not have failed to 
occur, even apart from the operation, in tliose cases in which incision is indi- 
cated at all. 

Recently an old, partly forgotten procedure has been again brought into 
use. This consists in scraping the ulcus serpens with a small sharp spoon. The 
loss of substance thus produced may be brushed over with antiseptic substances 
or with iodoform. 

Prophylaxis against the formation of an ulcus serpens is possible in the sense 
of our being able to remove iu season the source of infection, as, for instance, 
the secretion from a lachrymal sac affected with blennorrhoea. If, in such a 
case, a small erosion of the cornea exists, this is to be treated with special care 
by the application of disinfectant remedies. 

Even in cases of varioloui vlcers of the cornea prophylaxis undertaken in 
season would often prevent the infliction of great injury. During an eruption 
of smallpox the lids are much swollen, and hence are not opened by the pa- 
tient, and even the physician generally neglects to look at the eye from time to 
time. In that case, when the swelling of the lids goes down during the stage 
of desiccation and the patient opens his eyes again the morbid process in the 
cornea is often already in pi-ogress, and we are just so much behindhand in un- 
dertaking the treatment. Horner, therefore, is right in demanding that a 
physician treating a smallpox patient should prevent the agglutination of the 
lids by applying a pledget smeared with ointment, should examine the eyes 
every day, and should cleanse the conjunctival sac with antiseptic solutions. 
Careful watching will enable us to recognize the very commencement of the 
corneal disease, which in these early stages presents the most favorable condi- 
tions for treatment. At the time when smallpox was very widespread it 
formed one of the most frequent causes of blindness, so that about one third of 
all cases of blindness were produced by it. Since smallpox, owing to the in- 
troduction of vaccination, has become less prevalent, the blindness due to it 
has correspondingly diminished. Thus, in France, before the introduction of 
vaccination, thirty-five per cent— and after its introduction seven per cent— of 
all the blind lost their eyesiglit by reason of smallpox (Carron du Villards). 
In Prussia, before the introduction of compulsory vaccination, thirty-flve per 
cent— after its introduction two per cent— of all the blind people in the coun- 
try were rendered so by smallpox. 



174 DISEASES OF THE EYE. 

S. Keratitis e LagophtJialmo. 

37. Keratitis e lagophthalmo originates from a desiccation of the 
cornea in consequence of its being insufiSciently covered by the lids. 
The conjunctiva of the eyeball, wherever it lies constantly exposed to 
the air in the open palpebral fissure, appears reddened, and generally 
somewhat swollen as well. It secretes a small amount of discharge, 
drying upon the conjunctiva in crusts, which not infrequently also 
cover the exposed portion of the cornea. After removing the crusts 
we find the cornea dry on the surface, dull, slightly depressed, and at 
the same time clouded and gray. In the subsequent course of the 
disease the cloudiness becomes more and more intense, until finally 
disintegration of the superficial layers of the cornea takes place, with 
the consequent formation of an ulcer. At the same time there exists 
iritis with hypopyon. The ulcer may heal without perforation, but 
leaving an opacity behind it, or it may perforate the cornea, and thus 
lead to prolapse of the iris, or even to panophthalmitis. 

The cause of keratitis e lagophthalmo is the desiccation of the cor- 
nea in consequence of the defective closure of the lids (lagophthalmus). 
Owing to this desiccation the corneal epithelium becomes fissured and 
desquamates in spots. Then germs migrate into the corneal lamellae 
thus exposed, and produce suppuration. 

The defective closure of the lids arises either from mechanical ob- 
stacles, such as contraction of the lids, marked protrusion of the eye- 
ball, etc., or from paralysis of the orbicularis palpebrarum. In high 
degrees of lagophthalmus the cornea is uncovered all the time ; in 
lighter cases, on the contrary, in which the closure of the lids is not 
impossible but only impeded, the danger of desiccation taking place is 
particularly present during sleep. In daytime, owing to the feeling of 
dryness of the cornea, the act of winking is pretty frequently excited 
through reflex action, and thus the cornea is repeatedly moistened. 
But in sleep the reflex winking of the lids is absent, and hence the cor- 
nea is unmoistened by this means and becomes dry wherever it lies ex- 
posed in the open palpebral fissure. The desiccation in this case always 
affects the lowermost part of the cornea, because in sleep the eyeball is 
turned upward, and hence the lower part of the cornea lies in the pal- 
pebral fissure. The corneal lamellse, as fast as they become desiccated, 
die and are cast oflE by a process of suppuration. An ulcer is then 
produced which extends below as far as the margin of the cornea, while 
above it reaches a greater or less distance, according to the extent to 
which the cornea is uncovered, and ends in a horizontal border. This 
desiccation of the lowermost portion of the cornea occurs when the 
lids remain incompletely closed because the consciousness is clouded, as 
is the case in persons who, in severe diseases, lie unconscious for a long 
time. If such patients escape with their lives, they may have opaci- 



DISEASES OP THE COKNEA. I75 

ties of the cornea in both eyes in consequence of keratitis e lagoph- 
thalmo, or they may even lose their eyes altogether. 

The treatment consists in taking care that the cornea shall be cov- 
ered by the lids. In this way the development of a keratitis is pre- 
vented by prophylaxis, or, if a keratitis already exists, the chief condi- 
tion is afEorded for its cure. AVe must accordingly initiate the proper 
treatment for the cure of the lagoph thalmus (see § 112), and in the 
meantime, until a cure has been accomplished, take pains to effect a 
perfect closure of the lids by means of a properly applied bandage. In 
order to do this, it is generally necessary to fasten the lids themselves 
together by strips of sticking plaster before the bandage is applied 
over the eye. 

In slight cases of lagophthalmus it is sufficient to keep the eye 
bandaged through the night only. But if the lagophthalmus is con- 
siderable, or if keratitis has already set in, the eye must be kept band- 
aged all the time. If the treatment is initiated early, the prognosis is 
good, inasmuch as the process comes to a standstill as soon as the 
desiccation of the cornea is arrested. 

^. Keratomalacia. 

38. Symptoms and Course. — Keratomalacia * occurs only in child- 
hood. The disease begins with night blindness (hemeralopia). This 
consists in the patient's visual power being perfectly good in bright 
daylight, but so very greatly reduced when the illumination is dimin- 
ished (e. g., in twilight) that>he is often no longer in a state to go 
about alone. In very small children who do not go about alone yet, this 
symptom naturally can not be made out. In such children, the first 
thing that strikes us is the dryness of the conjunctiva, which next de- 
velops, and which appears under the form of triangular xerotic spots 
on both sides of the cornea (see page 120). The conjunctiva in these 
spots is covered with a fine white substance like foam, and, as the 
lachrymal fluid can not moisten it, looks as if smeared with grease. The 
dryness extends rapidly over the rest of the conjunctiva and also over 
the cornea. The latter becomes dull, insensitive, and uniformly cloudy. 
Soon the cloudiness in the center of the cornea increases, a gray infil- 
trate forming there. This spreads rapidly, takes on the yellow color of 
pus, and terminates in the disintegration of the cornea— a disintegra- 
tion which, in bad cases, may- take place within a few hours. In the 
beginning the affected eye is not discolored ; afterward, when the cor- 
nea is already greatly involved, there appears about the latter a dusky 
venous injection. The lachrymal secretion is not increased, but rather 
diminished ; moreover, other symptoms of irritation, like photophobia 
and blepharospasm, are slight or are wanting altogether. The striking 



* Softening of the cornea, from [/c^pas, horn, and] /laKaKds, soft. 



176 DISEASES OF THE EYE. 

contrast between the severity of the corneal affection and the insignifi- 
cance of the accompanying symptoms of irritation, together with the 
dryness of the eye, stamps the disease with quite a peculiar character. 
This affection usually attacks both eyes. 

Children suffering from keratomalacia show a disturbance of the 
general condition, which is generally pronounced even before the out- 
break of the eye trouble, and which afterward grows still greater. The 
children become strikingly apathetic, have diarrhoea alternating with 
constipation, become rapidly emaciated, and often ultimately die either 
from exhaustion or from a complicating bronchitis or pneumonia. 

The prognosis in very small children is bad, as in most cases they 
lose not only their eyes, but their lives as well. In somewhat older chil- 
dren the disease runs a less severe course, so that they escape with their 
lives and get off with smaller or larger cicatrices of the cornea ; indeed, 
the cornea itself may subsequently clear up once more (G-ouvea). 

Etiology. — Keratomalacia is the result of an insufficient nourish- 
ment of the cornea, which evidently is only one of the symptoms of a 
severe general disease. The real nature of the latter is indeed at pres- 
ent unknown to us, although there are various facts that do not permit 
us to doubt its existence. Thus the hemeralopia is nothing but the 
expression of the depressed nutrition of the retina. The latter still 
performs its functions well when it is acted upon by powerful impres- 
sions, such as images made by a strong light. But as soon as the 
brightness of the images falls below a certain limit, the images of the 
object are no longer able to excite the retinal elements, the energy of 
which has been depressed (torpor retinae). This condition is in har- 
mony with the general apathy exhibited by these patients. Another 
thing that points to a severe general disorder is the rapid decline of 
strength, which often develops in an altogether inexplicable fashion 
even in those cases in which the children at the beginning of the dis- 
ease were apparently healthy. 

Keratomalacia develops, as a rule, in consequence of enfeebling in- 
fluences affecting th6 children, and acting detrimentally upoQ their 
nutrition. Among these influences belong insufficient or unsuitable 
nourishment (rearing of children by hand), severe diseases like scarlet 
fever, measles, typhus, etc., and particularly hereditary syphilis. The 
disease occurs in Eussia much more frequently than with us, as there 
it attacks infants during and after the time of the great fast, because 
during this period the mothers lose their milk in consequence of fast- 
ing. For a similar reason it is frequently observed in Brazil among 
the badly nourished children of the negro slaves. 

Keratomalacia does not occur in adults, although the kind of 
hemeralopia that occurs with xerosis of the conjunctiva (see § 104), 
and which likewise occurs chiefly in poorly nourished persons, may be 
a milder form of the same disease. 



DISEASES OP THE COKNEA. 177 

The chief task that treatment has to accomplish is to support the 
child's strength by means of fitting nourishment. In addition we 
must try to stimulate the vitality of the tissue of the cornea, a thing 
best performed by means of moist and warm compresses placed upon 
the eyes. If the apathetic little patients do not close their lids prop- 
erly, the cornese must be protected from desiccation by bandaging the 
eye. 

5. Keratitis Neuroparalytica. 

39. Symptoms. — In this affection, which occurs in consequence of 
paralysis of the trigeminus, the cornea becomes dull and slightly 
cloudy. Then the epithelium begins to be thrown off, first at the 
center, then more and more peripherally, until at length the entire 
cornea, with the exception of a marginal rim two to three millime- 
tres broad, is bared of its epithelium. This gives the cornea quite a 
peculiar appearance, such as is found in no other disease of it. In the 
meantime the cloudiness of the cornea also has increased. This is 
most marked in the center, and there is uniformly gray ; toward the 
margin it gradually decreases, and may be resolved by the magnifying 
glass into separate gray maculae. Subsequently the hue of the cloudi- 
ness becomes yellowish, hypopyon sets in, and ultimately the cornea in 
its center breaks down into pus. Thus a large ulcer forms, which cica- 
trizes with inclusion of the iris, and generally with flattening of the 
entire cornea. Not all cases, however, run so severe a course ; the 
keratitis may get well without the occurrence of any purulent disinte- 
gration of the cornea, although there always remain an opacity of con- 
siderable dimensions, and often, besides, a flattening of the cornea. 

The course of the disease is slow, and is characterized by the slight- 
ness of the associated symptoms of irritation. There is, indeed, marked 
ciliary injection but no laehrymation, since the secretion of the lachry- 
mal gland, due to reflex action, is diminished or abrogated. Owing to 
the coincident paralysis of the trigeminus, pain obviously is altogether 
absent. 

The prognosis is unfavorable, treatment having very little influence 
on the course of the disease, which, whether the formation of ulcers 
does or does not take place, leads, almost without exception, to the 
production of a dense opacity over the entire cornea, and hence to an 
almost complete annihilation of the visual power. 

Keratitis neuroparalytica has its cause in a paralysis of the tri- 
geminal nerve, which induces trophic disturbances in the cornea. 
The paralysis of the trigeminus also causes the simultaneous arrest 
of secretion of the lachrymal gland as well as the absence of pain. 
It is a matter of indifference whether the lesion which causes the 
paralysis of the trigeminus affects the trunk of the nerve or its 
nucleus of origin in the brain. 
13 



ITS DISEASES OF THE BYE. 

The treatment consists in the application of a bandage, warm com- 
presses, and atropine. Besides, we may try electricity, or, following 
NieJen's recommendation, strychnine (three to five milligrammes by 
hypodermic injection beneath the skin of the temple). 

The three affections of the cornea just described — keratitis e lagophthalmo, 
keratitis neuroparalytica, and keratomalacia — have been frequently confounded 
with each other. Thus the keratitis e lagophthalmo, which makes its appear- 
ance in patients during the death agony, has been regarded as a keratitis 
neuroparalytica, its cause being attributed to the depressed state of the nerv- 
ous influence. Conversely, some have explained keratitis neuroparalytica and 
keratomalacia as produced by desiccation of the cornea, and in this way 
have placed them in the same category with keratitis e lagophthalmo. Many 
authors deny absolutely the existence of keratitis neuroparalytica as an icde- 
pendent afllection. Hence this latter should be the first to receive careful con- 
sideration. 

The theory of keratitis neuroparalytica was founded by Magendie, who found 
that after section of the trigeminus in animals a keratitis made its appearance. 
He referred this to trophic disturbances. Snellen and Senftleben showed that 
the development of keratitis could be prevented by sewing to the eye a metallic 
capsule (the lid of a pipe). They hence concluded that the keratitis did not 
depend upon trophic disturbances, but was to be referred to traumatism ; for, 
as the animal has become destitute of sensation on the side operated upon, he 
strikes his eye against everything or rubs it against objects — e. g., against the 
walls of the cage in which he is confined. But inasmuch as simple mechanical 
injuries produce only attacks of cloudiness in the cornea, which rapidly pass 
off and never produce attacks of purulent keratitis like keratitis neuropara- 
lytica, the further assumption had to be made that the cornea, in cunsequence 
of the trigeminal paralysis, has a diminished power of resistance against exter- 
nal injuries. Then Peuer, by experiment, proved the inrorrectness of this ex- 
planation. After section of the trigeminus, the cornea can be injured in any 
way whatever beneath the metallic capsule sewed on in front of it, without 
anything but transient cloudiness of the cornea being produced. Hence, after 
section of the trigeminus, the cornea reacts toward external injuries just as it 
did before, and the cause of the efficacy of the metallic capsule must be sought 
for in something besides the prevention of traumatism. Peuer thought that he 
had found it in the fact that the metal capsule prevents the desiccation of 
the cornea. For in trigeminal paralysis the act of winking produced by reflex 
action is abolished; consequently the cornea becomes dry in its central, most 
exposed portion, and a delimiting suppuration develops about this dried and 
necrosed area. This sort of keratitis, which Feuer designated with the name 
of keratitis xerotica, is the alleged keratitis neuroparalytica. He was able to 
excite just the same sort of inflammation by producing lagophthalmus arti- 
ficially in animals with an intact trigeminus. For this purpose he sewed the 
two lids and the nictitating membrane so far back that they could no lono-er 
cover the cornea. Hence the efficacy of the metal capsule after section of 
the trigeminus consists, according to him, only in the fact that it prevents 
the desiccation of the cornea; for, as the animals strike the capsule ao-ainst 
the walls of the cage, they push the lids, to which it is fastened by sutures, 
in different directions over the cornea [and so moisten the eye]. Hence too 



DISEASES OF THE CORNEA. I79 

Peuer was able to obtain the same eflfect with an open ring of cork, which he 
sewed in front of the eyes. Then Peuer applied his results to man, and 
demonstrated that the keratitis which is seen to develop in soporose patients 
is clinically and anatomically identical with that which is developed in ani- 
mals and men through imperfect covering of the cornea (keratitis e lagoph- 
thalmo). He went too far, however, in denying altogether the existence of a 
true keratitis neuroparalytica. 

Tliere is no doubt that the keratitis which is sometimes in man observed 
in connection with trigeminal paralysis is in solitary instances caused by desic- 
cation of the cornea, and thus is a keratitis e lagophthalmo. The desiccation 
is produced by the abolition of the regular movement of the lids and by the 
deficiency of the secretion of tears. In this way, for instance, are those cases 
to be explained in which paralysis of the oculo-motor nerve, and consequently 
incomplete ptosis, exist at the same time with paralysis of the trigeminus, and 
in which the cornea, as occurs in keratitis e lagophthalmo, is aflected only in its 
lowermost portions which are not covered and protected by the drooping upper 
lid. But there are cases, nevertheless, which present the characteristic picture 
of genuine keratitis neuroparalytica as above described— a picture which is 
altogether different from that of keratitis e lagophthalmo. Moreover, it is de- 
veloped in those cases of trigeminal paralysis in which the movements of the 
lids and the moistening of the cornea are perfectly normal, or in which, in 
consequence of complete ptosis, the cornea is entirely covered by the lid, and is 
thus protected from desiccation. Furthermore, since the application of a band- 
age, which is a sure preventive of keratitis e lagophthalmo, is of no avail 
against the development of a true keratitis neuroparalytica, the latter can not 
depend upon desiccation of the cornea. Again, the frequently repeated injuries 
to which the development of keratitis neuroparalytica in animals has been re- 
ferred can not be thought of as existing in the case of a human being who takes 
good care of his eyes. Hence we can only explain keratitis neuroparalytica by 
the assumption of a trophic disturbance. The fact that it does not occur in all 
cases of trigeminal paralysis is no evidence to the contrary, for the disease may 
have affected only the sensory and not the trophic fibers of the trigeminus. 
The trophic fibers, according to the views of different authors, arise from the 
sympathetic and attach themselves to the medial aspect of the trunk of the 
trigeminus. In fact, keratitis neuroparalytica has been obtained after sections 
of the trigeminus affecting only the innermost fibers of the nerve, although, 
in consequence of the sensory fibers being intact, the cornea and the lids have 
retained all their sensitiveness. We are therefore obliged to acknowledge the 
existence of a genuine keratitis neuroparalytica, and to make a sharp distinction 
between it and keratitis e lagophthalmo. 

The confounding of the three forms of keratitis— keratitis e lagophthalmo, 
keratitis neuroparalytica, and keratomalacia — with each other has been favored 
by the fact that they display various features in common.. Among these are 
the dryness which the eyes exhibit, and also the insignificance of the irritative 
symptoms in comparison with the severity of the keratitis, an insignificance 
shown in the absence of increased lachrymal secretion, of blepharospasm, and 
often also of pain. And yet the dryness of the eyes in these three forms of kera- 
titis is to be referred to very different causes. 

(a) In keratitis e lagophthalmo an actual desiccation of the cornea from 
evaporation exists. It affects only the exposed portion of the cornea, and may 



180 DISEASES OF THE EYE. 

be relieved by closure of the lids. The desiccation in this case is the one cause 
of all the subsequent changes. 

(b) In keratomalacia the cornea is not actually dry, but only looks so, be- 
cause the lachrymal fluid does not adhere to its surface. This dry appearance 
is present even when the eye is swimming in tears or when it is kept constantly 
closed ; evidently, bandaging is of no effect against this sort of dryness. It is 
caused by a fatty metamorphosis of the epithelial cells, which consequently are 
not wetted by the lachrymal fluid. 

(c) In keratitis neuroparalytica there is neither real desiccation of the cor- 
nea, as in keratitis e lagophthalmo, nor a peculiar fatty condition of its surface, 
as in keratomalacia; on the contrary, the eye looks dry simply because, in spite 
of the marked inflammation of the cornea, the lachrymation, which we usually 
see under these circumstances in other cases, is absent. The secretion of the 
lachrymal gland is in fact diminished or altogether abrogated; nevertheless, the 
moistening of the eye is quite sufficient, as indeed it is after extirpation of the 
lachrymal gland. 

The absence of marked symptoms of irritation, which characterizes these three 
varieties of keratitis, is accounted for in the keratitis e lagophthalmo of very 
sick people and in keratomalacia by the general depression of strength, and in 
keratitis neuroparalytica by the insensitiveness of the eye. The irritative symp- 
toms, which in other cases are put in action through reflex impulses originating 
in the sensory nerves, are absent in the case of paralysis of the trigeminus. 

The three forms of keratitis are hence, in spite of their external similarity, 
entirely difllerent from each other, and can be readily differentiated by the 
clinical picture which they present. Keratitis e lagophthalmo occupies, as a 
rule, the lowermost part of the cornea. Keratomalacia begins in the center of 
the cornea, and is found only in children who are the subjects of a rapid decline 
of nutrition. Finally, keratitis neuroparalytica is characterized above all by 
the rapid exfoliation of epithelium over the whole extent of the cornea, and 
does not occur except in conjunction with a trigeminal paralysis which can be 
diagnosticated at once. 

The confusion between the three varieties of keratitis jnst described is fur- 
thermore favored by their nomenclature. The designation keratitis xerotica, 
chosen by Feuer for the keratitis of desiccation (keratitis e lagophthalmo), 
would be quite a good one if it did not lead to confusion with simple local 
xerosis of the cornea on the one hand and on the other with keratomalacia, in 
which xerosis of the conjunctiva and cornea likewise exists. And, as a matter 
of fact, some authors designate keratomalacia under the name of keratitis 
xerotica. In order to avoid this confusion, I have dropped the expression kera- 
titis xerotica altogether ; and as I do not wish to increase the number of epithets 
still further by the invention of a new name, I use the old expression keratitis e 
lagophthalmo for the keratitis of desiccation. 



B. Nonsuppurative Keratitis. 

(a) Superficial Forms. 

40. 1. Pannus.— Pannus consists in the new formation of a tissue 

resembling granulations directly beneath the epithelium of the cornea. 

Pannus is to be looked upon as an affection of the conjunctival layer 



DISEASES OP THE CORNEA. 181 

of the cornea (conjunctiva corneae, see page 40), and in every instance 
is simply one of the symptoms of a conjunctival disease — that is, either 
of conjunctivitis trachomatosa or conjunctivitis eczeraatosa. We hence 
make a distinction between pannus trachomatosus and pannus eczema- 
tosus. For further particulars, see under these two diseases of the con- 
junctiva. 

2. Keratitis with the Formation of Vesicles.— Vesicles on the cor- 
nea are generally small, and are filled with a limpid liquid. Their an- 
terior wall is very frail, for it is formed simply by the epithelium of the 
cornea, which is lifted up from Bowman's membrane by serum. More 
rarely larger-sized blebs (bullEe) occur, the anterior wall of which gen- 
erally consists of a new-formed connective tissue in addition to the epi- 
thelium, and is hence more resistant. The small vesicles are ordinarily 
present in some numbers, while the large blebs generally occur singly. 
Violent symptoms of irritation, such as ciliary injection, lachrymation, 
photophobia, and more especially great pain, are usually present dur- 
ing the development of the vesicle. These, doubtless, are caused by 
the pulling upon the corneal nerves which pass into the epithelium, 
and which, in the process of formation of vesicles, are first stretched 
and finally torn in two. The irritative symptoms ordinarily disappear 
with the rupture of the vesicles. This occurs so quickly in the case of 
small vesicles that we generally do not get a sight of these themselves 
at all, but only of the subsequent small epithelial defects to the mar- 
gins of which the detached epithelium still adheres in loose shreds. 
The large blebs, on account of the greater firmness of the anterior 
wall, are of longer duration. They are not tightly distended, but form 
a lax, tremulous, somewhat dependent sac. After their rupture the 
lax anterior wall still lies upon the cornea, and can be readily made out 
by the way in which it can be displaced by movements of the lids. 
The sensitiveness of the cornea to touch is ordinarily diminished or 
entirely abrogated in cases in which there is a formation of vesicles. 

There are the following varieties of keratitis with the formation of 
vesicles : 

(a) Herpes * Fehrilis Cornem (Horner). — In febrile diseases, espe- 
cially of the respiratory organs (most frequently in epidemic influenza, 
next oftenest in bronchitis, pneumonia, ordinary influenza, etc.), less 
frequently in other febrile diseases, like typhus, intermittent fever, etc., 
small vesicles often make their appearance on the lips, the alae of the 
nose, the eyelids, the ears, etc.f At the same time an eruption of small 
transparent vesicles, which are associated with violent symptoms of 
irritation, may occur upon the cornea. These are scarcely the size of 
a pin's head, and are often disposed in rows or in groups. The vesi- 
cles very speedily rupture, leaving small abrasions, the floor of which 

* Prom iifnrew, to creep. f Hebra's herpes facialis. 



182 DISEASES OP THE EYE. 

shows a faint opacity. Generally these abrasions soon heal, so that 
after two or three weeks the disease is over, without leaving any lasting 
opacity of the cornea. In severe, and especially in neglected, cases, 
however, large corneal ulcers, which not infrequently have a branching 
form (keratitis dendritica, see page 160), may develop from the small 
abrasions. 

There is no doubt that the vesicles upon the cornea are entirely 
analogous to those that develop upon the skin. Just as the latter are 
generally present only upon one side of the face, so also the affection 
of the eyes is usually unilateral in its development, and is, moreover, 
confined to the same side as the vesicles upon the face. With careful 
treatment the prognosis is good, as in that case the disease generally 
gets well without leaving any opacity. The treatment is purely symp- 
tomatic, being that which is indicated for corneal ulcers generally — 
that is, in the main, the employment of a protective bandage and of 
atropine. 

(/8) Herpes Zoster CornecB. — This is one of the symptoms of herpes 
zoster* ophthalmicus — that is, zoster which is localized in the region 
of distribution of the trigeminus (see the section on Diseases of the 
Lids, § 106). The cornea participates in the morbid process by form- 
ing small vesicles, which generally are arranged in groups and rupture 
speedily, as in the case of herpes febrilis. From the latter, herpes zos- 
ter is distinguished by running a considerably severer course, since the 
irritative symptoms persist after the rupture of the vesicles, the paren- 
chyma of the cornea at the spots where the vesicles were situated be- 
comes markedly opaque, and iritis occurs in conjunction with the 
keratitis. It takes a longer time for the opacities to disappear, nor is 
it always the case that they disappear completely. Naturally this is 
even more true of those cases in which large ulcers develop from the 
vesicles. The insensitiveness of the cornea to touch is especially pro- 
nounced in herpes zoster. Eeduction of the intra-ocular tension not 
infrequently exists so long as the inflammation is still recent. The 
prognosis of this variety of herpes, from what has Just been said, is less 
favorable than that of herpes febrilis ; the treatment is the same. 

(y) Keratitis Vesiculosa {ef Bullosa). — This variety occurs in eyes 
the cornea of which is more or less clouded and insensitive ; in eyes with 
a large corneal cicatrix, or eyes which have been rendered blind by 
irido-cyclitis, or by increase of tension. Either vesicles which are small 
and of short duration form with the accompaniment of violent inflam- 
matory symptoms upon the cornea (keratitis vesiculosa), or large tremu- 
lous bulls develop, which last for several days before they rupture (kera- 
titis bullosa). In all cases the vesicles show a great tendency to take 

* = girdle-eruption, from iaariii), girdle. We also speak of it as zona ophthal- 



DISEASES OF THE CORNEA. 183 

on frequent recurrences, in each of which the irritative symptoms set 
in anew. 

The cause of the formation of vesicles appears to lie in the abnor- 
mal conditions of lymph circulation that are without doubt present 
in sucli eyes. By stasis of the lymph cedema of the cornea is produced ; 
the (Edematous fluid penetrates forward until it gets beneath the epi- 
thelium, and then lifts the latter up in places from Bowman's mem- 
brane. 

The prognosis is so far unfavorable in that the disease frequently 
recurs, on which account the affected eye, besides being useless for pur- 
poses of vision, is the source of constant discomfort to the patient. 
Treatment should aim at relieving the condition of irritation produced 
by the eruption of vesicles, and at preventing the recurrences. The 
former object is attained by opening the vesicles, the smaller ones being 
, pricked, and in the case of the larger ones the anterior wall being 
removed. When the vesicles recur frequently at the same spot we 
must try to modify the character of the base from which they develop 
by removal of the vesicle wall with the galvano-cautery, by superficial 
cauterization of the spot with a nitrate-of -silver solution, or by ablation 
of the most superficial layers of the cornea. Sometimes we do not put 
a stop to the recurrences until we have improved the conditions for the 
nutrition of the eye by means of an iridectomy ; we may even find our- 
selves compelled to perform enucleation of the diseased eye in order to 
give the patient ease. 

Apart from the forms above described, the formation of vesicles upon the 
cornea is further, in rare cases, observed under special conditions — e. g., as a re- 
sult of the action of various, and particularly of corrosive, substances upon the 
cornea, after burns, after a cataract operation beneath the bandage, etc. For 
the vesicles that usher in fresh recurrences of former erosions of the cornea, see 
§ 43. Cases also occur in which, without known cause, there develop upon a 
perfectly sound cornea vesicles or bullae the formation of which we are inclined 
to attribute to nervous influences, as we do also in the case of herpes febrilis 
and herpes zoster. Cases of this- sort are usually characterized by periodical 
recurrence. I know one old lady who for twelve years suffered from occasional 
attacks of inflammation in her eyes, which otherwise were sound. The attack 
occurred once or twice a year, and afllected sometimes one eye, sometimes the 
other. It was associated with violent pain, great photophobia, and profuse lach- 
rymation. In the first days of the attack the only things found were cedema 
of the lids, great ciliary injection, and a cornea covered with minute elevations, 
as if it had been strewn with sand. Then a large transparent bulla developed 
upon the cornea, after the rupture of which the inflammatory symptoms rapidly 
abated and the epithelial defect healed without leaving a trace behind. 

A form of superficial keratitis which is related to herpes febrilis cornea?, 
but is not associated with the formation of vesicles, is l-erntitis ■pmictiita siiper- 
fciab's. It begins with the symptoms of an acute conjunctivitis. Changes 
in the cornea are observed either at the same time or not till some days or 
weeks afterward. These changes consist in the presence of minute gray spots 




184 DISEASES OF THE EYE. 

which, as in the case of herpes febrilis, are often arranged in groups or in short 
rows (Fig. 54.) They are sometimes only ten to twenty in number, sometimes 
very abundant — upward of a hundred. They are either scattered irregularly 
over the cornea, or they are chiefly massed together in the central portion ; in 
every case, however, the marginal portions of the cornea are the part least 
covered by the spots. The spots lie in the most superficial layers of the cornea, 
which latter looks dull because the epithelium over the 
spots bulges out in the form of a nodule. The irrita- 
tive symptoms soon vanish, but the spots, as well as the 
punctate look of the corneal surface, generally remain 
for months almost unchanged, and then very gradually 
disappear. If the spots are not numerous, the sight 
remains undisturbed ; if, however, many spots are pres- 
ent, particularly in the center, the acuity of vision is 
iG. . .— ERATiTis reduced considerably. Keratitis punctata superficialis 

is found most frequently in young people, and affects 
sometimes one, sometimes both eyes. It often begins at the same time with a 
catarrh of the air passages, just as herpes febrilis corneoe does, but is distin- 
guished from the latter mainly by the absence of the formation of true vesicles. 
Hence, too, in keratitis punctata superficialis the superficial losses of substance, 
which develop from the vesicles in herpes, are wanting, and for the same reason 
the formation of ulcers in this variety of keratitis is observed only as a rare ex- 
ception. 

In various slight, superficial affections of the cornea, in which its epithelium 
is affected, we observe that fine filaments are formed, which adhere by one end 
pretty firmly to the surface of the cornea, while the other end, which is often 
swollen in a club shape, hangs down free. This phenomenon has been described 
as Jilamentary heratitia (Leber, TJhthoff, Fischer). The filaments are produced 
by a process of outgrowth from the epithelial cells of the cornea (Hess, Nuel). 

(J) Dee2} Forms of Non- Suppurative Keratitis. 

41. These forms have as a common characteristic the develop- 
ment of an infiltrate in the middle and deep layers of the cornea, 
an infiltrate, however, which shows no tendency toward purulent dis- 
integration, but — generally not till after existing quite a while — disap- 
pears again by resorption. When this takes place, the cornea in favor- 
able cases clears up again completely, while in other cases opacities of 
a varying degree of intensity are left, and are sometimes even accom- 
panied by flattening of the cornea. In keeping with the deep posi- 
tion of the infiltrate in the cornea, the uveal tract, and especially the 
iris and ciliary body, are almost always implicated. 

S. Parenchymatous Keratitis* 

Symptoms and Course. — This afPection may run its course in two 
ways, according as it begins in the center or at the margins of the 

* Synonyms: keratitis interstitialis, keratitis prof unda, keratitis diffusa, uveitis 
anterior. 



DISEASES OP THE COEKEA. 185 

cornea. If the disease invades the center of the cornea first, we see 
small, dim, gray maculae making their appearance in this situation, 
and lying in the middle and deep layers of the cornea ; the surface 
of the latter is lusterless and dull. The number of macule gradually 
increases, so that they keep extending farther and farther toward the 
margin ; but they are always massed most thickly in the center, where 
they frequently become confluent. Since even between the maculse 
the cornea is not clear, but shows- a fine diffuse cloudiness, the entire 
cornea may in severe cases get to look uniformly gray, like ground 
glass. As soon as the opacity of the cornea has advanced somewhat 
farther, vascularization begins by the penetration of vessels into the 
cornea from different spots upon the corneal circumference. We see 
the vascular trunks coming out from beneath the limbus, because — as 
opposed to the vessels in pannus — they arise from the deeply situated 
vessels of the adjacent sclera (Figs. 43 and 44). They branch in tufts, 
like a brush, in the deep layers of the cornea, and often appear quite in- 
distinct and of a dirty-red or grayish-red color, because they are cov- 
ered by the clouded superficial layers of the cornea. 

In those cases in which the disease begins at the margin of the cor- 
nea, the first thing that strikes us is that the latter has grown luster- 
less and clouded at some spot upon its margin. The cloudiness is 
deeply situated, and when regarded with the naked eye looks uniformly 
gray, but with the magnifying glass can generally be resolved into sepa- 
rate maculse or dim parallel streaks. Soon similar areas of cloudiness 
appear at other spots of the corneal margin, and then push their way 
forward concentrically from all sides toward the center of the cornea. 
Simultaneously with the appearance of the marginal opacities the cor- 
responding portions of the limbus become injected and the vessels of 
the corneal margin begin to grow out. The formation of vessels, as 
far as it originates in the network of marginal loops in the limbus, 
soon comes to an end, so that the limbus advances only a little way 
out upon the cornea, where it looks red and swollen (" epauletlike " 
swelling of the limbus). On the other hand, the deep vessels, which 
come out from beneath the limbus, grow farther and farther into the 
cornea, and follow closely upon the opacity which advances in front 
of them ; it looks as if they were pushing the opacity before them. 
These vessels have, as in the case of those of the first form, the char- 
acters of deeply situated vessels, shown by their penicillate branching 
and by their dull, dead, grayish-red hue. 

When parenchymatous keratitis has attained its acme, the cornea 
is often so opaque that we scarcely recognize the iris through it. At 
the same time it loses its luster completely, so that it looks as though 
smeared with grease (with the magnifying glass we recognize numer- 
ous minute elevations of the epithelium, which make the surface of 
the cornea rough, as if made of fine shagreen). Sight is so reduced 



186 DISJ5ASBS OF THE EYE. 

that the patient can only count fingers held very close to him, or, still 
worse, can only recognize the movement of the hand before his eye. 
Now gradually the process of recovery begins, starting from the mar- 
gin, virhere the cornea first becomes transparent again, while at the same 
time the vessels grow constantly fewer and fewer. The center of the 
cornea remains opaque the longest, but finally clears up, too, until only 
a fine diffuse cloudiness remains, which causes but little impairment of 
sight. This cloudiness, together with a few very minute blood-vessels 
which are only visible with the magnifying glass, can still be made out 
years afterward, and are certain signs of the previous existence of a 
parenchymatous keratitis. 

Parenchymatous keratitis always runs a chronic course. The in- 
flammatory symptoms keep on increasing for one or two months, until 
the disease has reached its acme. Then the irritative symptoms very 
soon abate, and the process of clearing up of the cornea makes at first 
rapid progress. Afterward, however, it goes on more slowly again, and 
the center of the cornea in particular remains for a long time opaque, 
so that sight is not restored until late in the disease. It takes from 
half a year to a year, or even more, for the cornea to acquire the full 
degree of transparency which it is possible for it to assume with an in- 
flammation of the given intensity. 

All the cases do not run their course in the way described. There 
are, for example, many lighter cases in which the changes do not go 
far, and which hence, too, are completed in a shorter time. Thus the 
process may go no further than the formation of a few maculee, which 
gradually disappear again without the associated inflammatory symp- 
toms being at any time marked. If the opacity begins at the margin 
of the cornea, it often remains confined to that section of it from which 
it originally started. In that case, if it pushes its way farther from 
the margin toward the center, only a sector, and not the entire cornea, 
is rendered opaque. Conversely there are also — luckily not often — 
very severe cases in which dense opacities remain as a permanency. 
Again, owing to the inflammatory infiltration, softening of the cornea 
may be produced, so that the latter gives way before the intra-ocular 
pressure and keratectasia develops ; in this case also the cornea remains 
permanently opaque, and to quite a marked degree. The worst cases 
are those in which, by subsequent shrinking of the exudate, the cornea 
becomes flattened, densely opaque, and of a tendinous appearance, in 
which case the sight is nearly or quite lost. 

_ Just as great variations exist in regard to the density and extent 
of the infiltration, so they do also in regard to the vascularization. In 
many cases the cornea is so abundantly vascularized that it looks like a 
red cloth; in others, on the contrary, it is almost devoid of vessels, and 
is like white ground glass. Lying between these extremes are numer- 
ous cases in which vessels develop from only single spots upon the cor- 



DISEASES OP THE COENEA. 187 

neal margin, so that simply a sector of the cornea looks red, or so that 
only single tufts of vessels are discoverable. Hence we may distinguish 
between a vascular and a non- vascular form, according to the relation? 
of the vessels. It must be remarked, however, that even in the non- 
vascular form one 'or two vessels can generally be made out with the 
aid of the magnifying glass. 

When we consider how the cases vary both in respect to the opacity 
and to vascularization, we comprehend why parenchymatous keratitis 
should present a very varying clinical picture, and hence often offer diffi- 
culties in the way of diagnosis for the beginner. But we shall generally 
be able to make the diagnosis with certainty if we hold fast to those 
symptoms which are common to all the cases — namely, the deep situa- 
tion of the opacity and of the vessels, the typical increase in the in- 
filtration up to a certain, usually considerable, degree, and finally the 
absence of purulent disintegration, so that the formation of ulcers 
never takes place. 

Parenchymatous keratitis is accompanied by irritative symptoms, 
such as pain, photophobia, and lachrymation. These are sometimes 
very slight, sometimes violent; in general we may say that they are 
more pronounced, the greater the amount of vascularization with which 
the keratitis is associated. Furthermore, parenchymatous keratitis is 
almost always complicated with inflammation of the uveal tract. In 
the lightest cases there is merely hypereemia of the iris, which makes 
itself apparent by the failure, complete or nearly so, of the pupil to 
dilate under atropine. In severe cases there is iritis, which may lead 
to the formation of posterior synechia, the formation of deposits upon 
the posterior surface of the cornea, and seclusion and occlusion of the 
pupil. In particularly bad cases a plastic irido-cyclitis develops, which 
terminates in flattening of the cornea, or even in atrophy of the eyeball. 

Parenchymatous keratitis generally attacks both eyes, and more 
frequently both in succession than both at once. Sometimes there is 
even an interval of several years between the involvement of the two 
eyes. Kecurrences of the disease take place, but are not common. 

T\\(i prognosis of the disease, from what has been said, is unfavor- 
able as regards its duration, inasmuch as it drags on for months and 
years, especially if the two eyes are successively attacked. On the other 
hand, the prognosis in regard to the ultimate outcome must be put 
down as good, because in by far the greater number of the cases a good, 
or at least serviceable, degree of sight comes back. By holding up this 
prospect of recovery the physician must keep up the courage of his pa- 
tient, who, because of the slow progress of the disease, is very apt to lose 
all hope of a restoration of his sight. 

Etiology.— Parenchymatous keratitis is a disease of youth, appear- 
ing, as a rule, between the sixth and the twentieth year of life. It is 
only the exception that persons before or after this age (sometimes 



188 DISEASES OF THE EYE. 

even after the thirtieth year) are attacked. The female sex suffers 
from it more frequently than the male. The ordinary cause of the 
disease is syphilis, and especially hereditary syphilis. To prove the 
existence of hereditary syphilis from the history of the case directly — 
i. e., by getting the father or mother to confess to syphilis — is often a 
difficult thing to do. Besides, in most cases it is not at all necessary, 
since hereditary syphilis can generally be recognized vfith sufficient 
certainty from a series of symptoms. In that case, we abstain from 
questioning the parents in regard to this matter, the more so since 
it would be a severe reproach to them to have to recognize in their 
own persons the cause of their children's illness. On the other hand, 
it is a good thing to determine by questioning whether many children 
have died in the family (the mortality of the children of syphilitic 
parents amounts, on an average, to fifty per cent), whether premature 
labors, and especially those in which the fostus was dead or putrefied, 
have not occurred, etc. 

The symptoms of hereditary syphilis which patients with paren- 
chymatous keratitis frequently exhibit are as follows : 

1. A peculiar formation of the face and cranium. The upper jaws 
are markedly flat, and the bridge of the nose low and often sunken in. 
Not infrequently there exists ozsena or blennorrhoea of the lachrymal 
sac, the latter in consequence of the changes in the nose. The frontal 
eminences are very prominent. The intelligence of these patients is 
often abnormal, they being either precocious, or, on the other hand, 
backward in the mental development. 

2. The incisor teeth are abnormally shaped (Hutchinson), so that, 
instead of a straight edge, they show a semilunar indentation. This 
change exists only in the teeth of the second dentition, and then most 
frequently in the upper central incisor teeth. The incisor teeth are 
often also stunted in their growth as a whole, so that they are either 
too small or are altogether wanting. 

3. At the angles of the mouth we may find fine linear cicatrices as 
relics of former rhagades ; so also cicatrices in the buccal and pharyn- 
geal cavities (especially on the hard and soft palate) point to the exist- 
ence of antecedent syphilitic ulcerations. 

4. Numerous enlarged lymphatic glands can be made out, especially 
upon the neck. These are small, hard, painless, and with no tendency 
toward ulceration, by which characters they are distinguished from the 
lymph glands of scrofulous subjects, which are large and soft, and 
readily undergo caseation. 

5. Swellings of the periosteum (tophi), which are hard and are but 
little or not at all painful, occur on the long bones. They are most 
frequently and most easily found upon the anterior border of the tibia. 
Sometimes a serous inflammation of the knee joint (hydrops genu) is 
present ; caries is rare. 



DISEASES OE THE CORNEA. Igg 

6. We frequently find hardness of hearing, which, with the outbreak 
of the keratitis, sometimes increases to absolute deafness. 

It is important to look for all of these symptoms, for any one of 
them by itself is not to be looked upon as conclusive evidence of the 
existence of hereditary syphilis ; and, on the other hand, we ought not 
to expect to find all the changes above given distinctly marked in the 
same individual at once. The more carefully we make our investiga- 
tion, the greater is the number of these symptoms that we are able to 
establish ; so that we arrive at the conviction that by far the greatest 
number of cases of parenchymatous keratitis are to be referred to 
hereditary syphilis. In very rare cases this form of keratitis is also ob- 
served in acquired syphilis. A few cases may depend upon scrofula, 
while in many no cause at all that we can be sure of is discoverable to 
account for the eye disease. 

Treatment. — Local treatment during the period of progression con- 
sists in combating the inflammation by protecting the eyes from light 
and by instilling atropine, which latter counteracts the complications 
arising from the iris. Moist warm compresses often ameliorate the 
symptoms of irritation, and accelerate somewhat the progress of the dis- 
ease. In the regressive period, the thing to do is to secure as thorough- 
going a clearing up of the cornea as possible. For this purpose the 
well-known irritant remedies — like calomel, tincture of opium, yellow- 
precipitate ointment, hot steam, etc. — are indicated (see page 157). 
These, however, should only be brought into application when, on 
making cautious tests, the eye is found to bear them well — i. e., does 
not through their use fall into a state of renewed irritation. It is ad- 
visable to keep on with these remedies, interchanging them frequently, 
for a very long time — for months or years. If ectasis of the cornea 
threatens, it is to be combated by a pressure bandage, which, if neces- 
sary, can be combined with repeated paracentesis of the cornea. 

General treatment in those cases in which hereditary syphilis is 
the cause must be directed against the latter. Mercurial treatment, 
which is of such marked service in acquired syphilis, is here ordinarily 
less efficient. Since it is at the same time a very drastic method of 
treatment, it is advisable to apply it in the severe cases only. In adults 
we had best select the treatment by inunction. If from the circum- 
stances of the case this can not be done, we may give mercury inter- 
nally or still better in the form of hypodermic injection. A hypo- 
dermic syringeful of a one-per-cent sublimate solution (to which from 
one to five per cent of sodium chloride is added) may be injected once 
a day or once every other day into the glutei. In children the inter- 
nal administration of corrosive sublimate is preferable. We give pills 
of one milligramme, beginning with one a day, and increasing the dose 
to from six to ten pills a day, according to the age. In doing this we 
must be mindful to pay careful attention to the condition of the mouth. 



190 DISEASES OP THE BYE. 

in order to avoid salivation. In the lighter cases of parenchymatous 
keratitis we prefer, in place of mercury, a simple corroborative treat- 
ment with the simultaneous employment of remedies containing iodine 
(cod-liver oil with iodine, iodide of iron, and minei-al waters contain- 
ing iodine, the latter especially as a form of after treatment). Unfor- 
tunately, we must say that, in general, treatment is pretty nearly pow- 
erless against this disease. Parenchymatous keratitis in many cases, 
even under the most careful treatment, runs a course that is not essen- 
tially different from what would have been the case without any treat- 
ment ; not infrequently we see the disease while under treatment break 
out in the other eye, without our being able to prevent the opacity 
from spreading gradually over the entire cornea in this eye also. The 
chief use of treatment consists in its combating the complications aris- 
ing from the uvea, and also in securing a more rapid and more perfect 
clearing up of the corneal opacities during the period of regression. 

Up to the present time it has been possible to make an anatomical examina- 
tion of an eye affected with parenchymatous keratitis in a few cases only. The 
examination shows dense infiltration of the most posterior layers of the cornea, 
so that they sometimes appear as if transformed into granulating tissue (i, Fig. 
55) ; moreover, in the posterior and middle layers of the section we see numer- 
ous newly formed blood-vessels (Fig. 55, g). The infiltration at the margin 
of the cornea is continued into the ligamentum pectinatum, the iris, and the 
ciliary body. In one case (in a fourteen-year-old boy) I found this region infil- 
trated with numerous nodules which were composed of small cells and which 
had a certain resemblance to tubercles, although it was not possible for me to 
demonstrate the presence of tubercle bacilli or of other micro-organisms. In- 
stances of similar nodule formation have since then been observed by others, 
and it has hence been conjectured that parenchymatous keratitis may be caused 
by tuberculosis more often than has hitherto been supposed. 

According to the results of anatomical as well as clinical examination, there- 
fore, parenchymatous keratitis is situated in the most posterior layers of the 
cornea, which, according to the teachings of embryology, are to be classed with 
the uvea (see page 133). It should not, therefore, excite our astonishment if the 
uvea proper is also always implicated. To be sure, the participation of the uvea 
in the inflammation is not by any means equally pronounced in all cases. 
Minute deposits, which are discovered in making a careful examination of the 
cornea with the magnifying glass at the time when the opacity is resolving, are 
scarcely ever wanting. Besides these, the most frequently occurring complica- 
tions are posterior synechiije and also chorioiditic foci ; hypopyon, on the other 
hand, is extremely rare. In many cases the part that the uvea takes is so slight 
as not to be clinically demonstrable ; in other cases, on the contrary, it is so 
very prominent, as compared with the process in the cornea, that what we have 
before us is really an irido-cyclitis— the implication of the cornea being evi- 
denced only by the presence of a few spots of opacity in its deep layers. 
Thus there is a continuous series of intermediate forms between typical par- 
enchymatous keratitis and iridocyclitis e lue hereditaria. 

Among the more frequently occurring variations in the clinical picture of 
parenchymatous keratitis the following may be mentioned : In that form which 



DISEASES OP THE CORNEA. 



191 



begins with macula) in the central portions of the cornea it not infrequently 
happens that the maculae at a certain distance from the cornea are placed par- 
ticularly close together, and thus form a very opaque ring, which still remains 
visible as a gray circle even when the separate macula! have coalesced into 
a continuous mass of cloudiness (hence described by Vossius in brief as lera- 
titis centralis annula/ris). Allied to these cases are those in which the cen- 
tral part of the cornea becomes particularly opaque through the confluence of 




r r 

Fro. 55. — Cross section through a Cornea with Parenchymatous Keratitis. 
Magnified 100 x 1. (After a preparation of I>r. Nordenson.) 

The stroma, S, of the cornea shows an infiltration, which begins in the middle layers, and keeps 
on increasing more and more posteriorly, so that the deepest layers, i, have assumed the 
aspect of a granulating tissue. On account of the inequality in the degree of thickening of 
these layers, Descemet's membrane, I), is undulated ; upon its endothelium there are depos- 
ited in places small accumulations of round cells, r. In the middle and deep layers of the 
cornea we see the transverse and longitudinal sections of newly formed blood-vessels, </, £/, 
while the most anterior layers, and also Bowman's membrane, B^ and the epithelium, E^ are 
normal. 

the maculae, and forms a white disk pretty sharply separated from the less 
opaque, marginal portions of the cornea. I have seen several cases in which this 
central opacity remained permanently after the marginal portions had cleared 
up, and formed a dense, white, sharply circumscribed spot in the center of each 
cornea, just as if there had been a deeply penetrating central ulcer. 

Sometimes the distribution of the infiltration in the cornea is such that the 
densest opacity occupies the lowest part of the cornea, as if the products of 
inflammation had arranged themselves there in obedience to the law of gravi- 
tation. In that case the opacity is bounded above by a convex line, or it forms 



192 DISEASES OF THE EYE. 

a triangle, the base of which corresponds to the lower margin of the cornea, 
while its apex looks upward. The permanent opacity that results from this 
has the greatest similarity to those triangular opacities in the lower part of the 
cornea which are left by an iridocyclitis, when an exudate at the bottom of 
the anterior chamber has remained for a pretty long time deposited upon the 
posterior surface of the cornea. 

In irido-cyclitis resulting from acquired syphilis it not infrequently happens 
that isolated gray specks appear in the middle and deep layers of the cornea. 
These have been described by Mauthner, Hock, Purtscher, and others as Teera- 
titis punctata syphilitica. This is distinguished from keratitis punctata super- 
flcialis (page 183) not only by the etiology, but also by the situation of the 
specks in the deep layers of the cornea, and might therefore be appropriately 
characterized as keratitis punctata profunda. 

The vessels in parenchymatous keratitis generally lie in the deep layers. 
Yet it often enough happens that we find, especially with the aid of the mag- 
nifying glass, a few vessels also which evidently arise from the network of 
marginal loops or from larger conjunctival blood-vessels, and which therefore 
lie supei'flcially in the cornea. All vessels tend toward the center of the cornea, 
but do not generally reach it, so that here a roundish spot of the size of a millet 
seed or more remain unvascularized. The vascular, portions of the cornea look 
red, and, if the vessels are abundant, rise above the level of the non-vascular 
center; the latter, accordingly — which, in consequence of the marked infiltra- 
tion, is gray or even yellowish gray — is depressed. We must not on this ac- 
count allow ourselves to be misled and consider the depressed gray spot as an 
ulcer, for parenchymatous keratitis does not, as a general thing, lead to ulcera- 
tion. Exceptions to this rule, though rare, do, however, occur. I have seen, in 
fact, two cases in which perforation had taken place in the center of the cornea. 

The anterior chamher in parenchymatous keratitis is often found to be 
deeper than usual, a circumstance which should not, however, be referred with- 
out further consideration to an ectasis of the cornea, a thing which occurs quite 
rarely. On the contrary, the cause of it ordinarily is a recession of the iris due 
to the increased secretion of aqueous humor that results from the irritation of 
the iris. This irritation is in part responsible for the fact that during the ex- 
istence of the inflammation frequently no dilatation of the pupil can be obtained 
by atropine. But here there is evidently another factor that must be consid- 
ered, and that is that the atropine does not diffuse through the inflamed cornea 
to the same extent as it does through a sound one, so that it does not in fact 
get into the aqueous humor in sufficient quantity to dilate the pupil. 

The intra-ocular pressure not infrequently shows an alteration in parenchym- 
atous keratitis. Generally, it is diminished so that the eye appears softer, 
although we need not therefore imagine that an atrophy of the eyeball is be- 
ginning. An increase of tension is but rarely observed, and, when it is, some- 
times occurs years after the inflammation has run its course. I have seen this 
even in those cases in which no ectasis of the cornea has been left. Perhaps in 
such a case the increase in tension was to be attributed to the chorioiditis which 
accompanies many — in fact, most— cases of keratitis parenchymatosa. This 
chorioiditis is localized in the most anterior segment of the chorioid (chorioidi- 
tis anterior), which is covered with numerous— in most cases black — spots. 
This variety of chorioiditis would probably be set down among the most fre- 
quent symptoms accompanying parenchymatous keratitis if the examination 



DISEASES OP THE CORNEA. 193 

with the ophthalmoscope, and hence the determination of the presence of 
chorioiditis, Avere not rendered impossible while the inflammation lasted by 
the cloudiness of the cornea. The making of this examination and diagnosis 
can only be done when the cornea has cleared up once more after the inflam- 
mation has run its course. It is also often possible to make out the existence of 
peripheral chorioiditis in the other, as yet uninflamed, eye. 

Another and rarer complication of parenchymatous keratitis is a diffuse 
scleritis in the region surrounding the cornea. This may subsequently give rise 
to ectasiaa of the sclera. 

The typical course of parenchymatous keratitis, and the participation of both 
eyes in it, early suggested the idea of its being due to a constitutional cause. 
Thus Mackenzie gave an excellent description of this disease under the name of 
corneitis sorophulosa, and at the same time gave a number of the accompanying 
symptoms which he looked upon as signs of scrofula. Hutchinson has the 
credit of having completed this series of symptoms, and of having at the same 
time furnished the proof that they belong not to scrofula, but to hereditary 
syphilis. This novel view was slow in makirg its way. Many at first would 
only allow that it was true for a limited number of cases, and hence divided 
parenchymatous keratitis into two forms, which they called keratitis scrofu- 
losa and keratitis syphilitica. But the more precise our knowledge becomes in 
regard to the symptoms of hereditary syphilis, the more surely we ari'ive at the 
conviction that this disease lies at the root of parenchymatous keratitis, what- 
ever form the latter may exhibit. Parenchymatous keratitis belongs among 
the latest forms under which hereditary syphilis' appears, and is hence, and 
rightly, regarded as one of the most important and most frequent symptoms of 
the late hereditary form of the disease. 

The following history may serve to sliow how from difl;erent symptoms we 
get at the diagnosis of hereditary syphilis. A twelve-year-old girl with par- 
enchymatous keratitis of both eyes was brought into the clinic by her mother. 
The latter declared that she had no knowledge of syphilis as affecting either 
herself or her deceased husband. She only admitted that tlie latter had led 
an irregular life. The woman went on to say that she had been pregnant by 
this man ten times in all. From the first four pregnancies came four children 
(the eldest at present about twenty-two years old), who are all healthy. The 
fifth child died at the end of one year, the sixth pregnancy ended in an abortion, 
the seventh child is the little patient who is brought into the clinic, the eighth 
child died at the age of nineteen months, the ninth child is living but is always 
sickly, and the tenth died at the age of six weeks. Then the husband died in 
consequence of an accident; the woman married a second time, and has had by 
her second husband two perfectly healthy children. The woman's daughtei- who 
was brought into the clinic was deaf; she presented, in addition to the paren- 
chymatous keratitis of both eyes, the characteristic formation of the cranium 
belonging to syphilitic children. The teeth showed the form described by 
Hutchinson; numerous small, hard lymphatic glands were found upon the neck. 
I made the younger sister (the woman's ninth child) come too. She, who was a 
feeble girl, was not, to be sure, absolutely deaf, but heard very badly, had the 
characteristic formation of the face and swollen lymphatic glands upon the 
neck, and the teeth — they were the milk teeth — were markedly small and 
separated by wide interspaces. Externally the eyes looked healthy, but in both 
the periphery of the fundus was found by the ophthalmoscope to be covered with 
13 



194 DISEASES OP THE EYE. 

spots, black as ink, lying in the chorioid. The correct interpretation of this 
history, without doubt, is that the woman's first husband had acquired syphilis 
after the fourth pregnancy. While, therefore, the woman's first four children 
enjoy very good health, only two of the children of the six following births 
are living, and both are sickly, both marked with evident symptoms of heredi- 
tary syphilis. When the woman had become pregnant by her second, healthy 
husband, she had healthy children once more. 

From the history just submitted, it can be deduced that the examination of 
the little patient's brothers and sisters may often contribute to the clearing up of 
the case, inasmuch as we may find in them, too, symptoms of hereditary syphilis, 
and thus may still further confirm the diagnosis. Moreover, it is not at all rare 
for two or even three of a set of brothers and sisters to be affected with paren- 
chymatous keratitis. 

4- Keratitis Profunda* 

42. In this a gray opacity develops very gradually in the cornea 
— ordinarily in its center — an opacity which is situated in the middle 
and deep layers of the cornea, and over which the corneal surface is 
gray and punctate, but not depressed. Seen with the naked eye, the 
opacity looks uniformly gray, while with the magnifying glass it may 
be resolved into separate dots and maculae, or into gray interlacing 
strise. After the opacity has remained for some time (several weeks) 
at its acme it begins to slowly abate, without ulceration having taken 
place. The development of new vessels is either entirely absent or is 
very inconsiderable. The accompanying symptoms of inflammatory 
irritation are sometimes slight, sometimes pretty violent. The partici- 
pation of the iris is mostly limited to hypersemia. 

The disease attacks adults only. It lasts from four to eight weeks 
or more. In the lighter cases it terminates in a complete restoration 
of the transparency of the cornea, while in other cases diffuse opacities 
remain permanently in the center of the cornea. 

The causes of keratitis profunda are in the great majority of cases 
unknown. For individual cases the following causes have been given : 
1. The effect of cold. Arlt has characterized such cases as keratitis 
rheumatica. These ordinarily run their course with marked inflamma- 
tory symptoms, especially with violent pain and photophobia. 3. Inter- 
mittent fever in its chronic form of malarial cachexia sometimes re- 
sults in a keratitis profunda, which is characterized by the absence of 
marked symptoms of irritation, and also by an unusually chronic course 
(Arlt). 3. After injuries, especially contusions, a keratitis profunda not 
infrequently develops, the peculiarity of which is its comparatively rapid 
course and the speedy restoi-ation of the transparency of the cornea. 

Treatment consists, locally, in the application of a bandage or of 
protective glasses, and the use of atropine and moist warm compresses, 



* Synonyms ; central parenchymatous infiltration of the cornea, keratitis 
parenchymatosa circumscripta. 



DISEASES OF THE CORNEA. I95 

provided these are well borne. After the inflammatory symptoms have 
run their course, irritant remedies for clearing up the opacity are indi- 
cated. The general treatment depends upon the cause that we are able 
to discover for the keratitis. 

5. Sclerosing Keratitis. 

This is an accompanying symptom of scleritis (see § 53). If a 
scleritic nodule is situated near the margin of the cornea, there de- 
velops in the adjacent portion of the latter an opacity which is situ- 
ated in its deeper layers (Pig. 64). It has approximately the shape of a 
triangle, the base of which is situated at the corneal margin, while the 
rounded apex looks toward the center of the cornea and becomes 
gradually lost in the transparent cornea. The opacity thus occupies a 
sector of the cornea, the base of which corresponds to the scleritic 
nodule. In many cases other opacities of rounded or irregular shape 
also develop at a distance from the corneal border, and even in the 
center of the cornea. The opacities are gray or grayish yellow, and 
gradually increase in intensity until the cornea at the affected spot has 
become completely opaque. The surface of the cornea over the oioacity 
is punctate but not depressed ; vascularization is either altogether 
absent or is very slight, and, when it is present, is in the deep layers 
of the cornea. After the opacity has reached its maximum density, a 
gradual retrogressive process sets in, without ulceration having taken 
place at any time. The process of clearing affects the thin edge of the 
opacity and its apex, which looks toward the center of the cornea ; the 
greatest portion of the opacity remains permanently and becomes ulti- 
mately bluish white like the adjacent sclera, into which it passes with- 
out any sharp line of demarcation. At the spot where the opacity is 
found, therefore, it looks as if the sclera had pushed its way into the 
space occupied by the cornea — whence the name sclerosing keratitis 
(Von Graefe). 

Like scleritis itself, this keratitis that accompanies it shows repeated 
recurrences, and it may happen that in severe cases the entire cornea 
is sclerosed with the exception of a small area in the center. 

The symptoms of irritation which accompany this form of keratitis 
are excited less by it than by the scleritis and the inflammation of the 
uvea depending upon the latter. 

The treatment is essentially that of the scleritis. 

6. Keratitis springing from the Posterior Surface of tlie Cornea. 

When the posterior surface of the cornea is not washed by the 
aqueous humoi-, as it is in the normal eye, but an exudate or tissue is 
brought into apposition with it, the substance of the cornea becomes 
cloudy. To produce this effect, however, it is necessary that the appo- 



196 DISEASES OP THE EYE. 

sition should be kept up for a pretty long time. Hence this sort of 
opacity is not generally found in ordinary hypopyon, because the latter 
disappears too quickly, but is found in those more solid gray exudates 
which appear in the anterior chamber, particularly in scrofulous and 
syphilitic irido-cyclitis. Large deposits also, if they remain for a long 
time, usually leave behind them gray spots upon the cornea. Another 
thing besides exudates, that gives rise to the same form of keratitis, is 
the apposition of tissue to the back of the cornea, as occurs vi^ith pro- 
trusion of the iris, vpith cysts or other tumors of the iris, that reach 
to the cornea, and with lenses that have prolapsed into the anterior 
chamber. The opacity of the cornea develops at a point correspond- 
ing to that spot at which apposition takes place, occurring, there- 
fore, in the case of exudates, most frequently below. The surface 
of the cornea at this spot is dull, sometimes slightly uneven, and ap- 
parently gelatinous. The opacity is gray, and, after lasting a long 
time, becomes pretty dense, and is permeated by vessels which lie in 
the deep layers of the cornea. It never completely disappears, even 
after the causal lesion has been remedied. 

The mode of origin of this form of keratitis is probaibly to be con- 
ceived of thus : Contact of the cornea with foreign tissue alters the 
endothelium of Descemet's membrane. This alone, according to Leber's 
researches, protects the cornea from the aqueous humor. Now, if the 
endothelium becomes deficient, aqueous humor can penetrate into the 
tissue of the cornea, which consequently becomes cloudy. 

The clinical pictures under which non-suppurative keratitis makes its ap- 
pearance are exceedingly manifold. Only a certain number of them can be 
marshaled under fixed types, as has been done in the foregoing pages. Many, 
sometimes very peculiar, forms come under observation too rarely for us to be 
able to build up from them a typical disease picture; they can not at present 
be utilized except for purposes of record as individual cases. A few rather 
more fre(iuently occurring forms may be enumerated here as an appendix to 
those before described. 

7. Deep Keratitis in Irido-cyclitis.— In every case of marked irido-cyclitis 
the cornea is not perfectly clear, but slightly dull. But in many cases of severe 
irido-cyclitis the participation of the cornea is still more pronounced, an infil- 
tration of gray, or later often of yellowish, color making its appearance in its 
deep layers. This infiltration, under a process of vascularization, subsequently 
disappears, altliough it always leaves a permanent opacity behind it, associated 
in severe cases with flattening of the entire cornea. Vision in these cases is 
almost or quite annihilated, not merely on account of the change in the cornea 
but also, and chiefly, on account of the products of the irido-cyclitis. These 
cases, which, to be sure, are very rare, must not be confounded with those cases 
of parenchymatous keratitis that are associated with marked implication of 
the uvea. 

8. Deep Scrofulous Infiltrates occur under the form of extensive gray, 
subsequently yellow, opacities in the middle and deep layers of the cornea in 
conjunctivitis eczematosa. They may either proceed to suppurate, or they may 



DISEASES OF THE COKjSTEA. 197 

go on to resorption, in wliich case the cornea clears up — sometimes in a surpris- 
ing manner. For a more detailed account, see Conjunctivitis Eczematosa 
(page 94). 

9. Keratitis Marginalis Profunda.— This rare disease generally affects old 
people, and occurs for the most part in one eye only, rarely in both. There 
forms upon the margin of the cornea, with moderate symptoms of irritation, a 
gray, later grayish-yellow, or even purulent-yellow opacity, which directly ad- 
joins the sclera and hence extends under the limbus, while on the other hand it 
reaches for a distance of about two millimetres into the transparent cornea 
(Fig. 56 A). This marginal zone of opacity generally embraces from one third 
to one half of the circumference of the cornea (most frequently the upper part), 
or in rare instances surrounds the entire cornea. The surface of the cornea 
over the opacity is somewhat dull, but shows no loss of substance, and never 
any exfoliation of epithelium. The limbus soon pushes forward, and with its 
vessels covers the opacity. The irritative symptoms disappear in from one to two 
weeks, while the marginal infiltrate is transformed into a permanent gray opac- 
ity of the cornea. This opacity bears a great resemblance to the arcus senilis. 





Fig. 56 a.— Keratitis Marginalis Profunda. Fig. 56 B.— Striate OpAcrrT or the Cornea 

The finely striate marginal zone represents after a Cataract Extraction. The cica- 

the limbus, adjoining which above and on trix, a 6, left by the section, lies at the up- 

the outer and inner sides is the arc-shaped per margin of the cornea, 
infiltrate drawn in darker shading. 

from which it is chiefly distinguished by its not being separated by a transparent 
zone from the scleral margin, but passing into the latter without any clear line 
of demarcation. Iritis does not occur in connection with this affection of the 
cornea, nor does ulceration of the cornea, as a rule ; only twice have I seen small 
superficial ulcers develop upon the cornea. On account of the marginal situa- 
tion of the residual opacity, this form of, keratitis is without danger to the 
sight. 

10. Striate Opacity of the Cornea. — When we examine carefully an in- 
flamed cornea with a magnifying glass, we often discover gray strite in it. 
These may be short and irregular and run in the most diverse directions. This 
is commonly the case in keratitis profunda. At other times we see a system of 
parallel striae — e. g., in the dense opacities that occur in parenchymatous kera- 
titis jutting out from the margin of the cornea and extending toward its center. 
Again, strise may occur that take a radiating direction, all emanating from a sin- 
gle point — e. g., from a corneal ulcer. The anatomical changes that give origin to 
the striaa are not always the same. It may be that cells or fluid thrust the fibers of 
the cornea apart and so pass on between them, taking a linear course. Such a 
thing can be effected artificially by injecting liquid through a puncture made in 
the cornea. In doing this we fill a system of parallel chinks (Bowman's tubes) 
which cross the successive corneal lamellae at right angles. 

Isolated, long, very delicate gray lines appear to be produced by turbid 



198 DISEASES OP THE EYE. 

fluid filling one of the channels that lie in the substance of the cornea and lodge 
the nerves passing from the margin of the cornea to its center. 

Very frequently, however, striae are produced not by exudation, but by 
■wrinkling. This is pre-eminently the case with traumatic striate opacity. 

This is observed after incised wounds of the cornea, and most beautifully 
after the cataract operation. Within the first twenty-four hours after the oper- 
ation gray striae make their appearance in the cornea, which, starting from the 
wound, extend sometimes as far as the opposite margin of the cornea, and are 
always disposed perpendicularly to the length of the wound (Fig. 56 B). 
These striae are particularly observable in those cases in which the lips of the 
wound have been somewhat contused, as, for example, those in which the de- 
livery of the lens has been difficult. They generally pass off within the first 
eight days, and it is only when specially pronounced that they take several 
weeks to disappear. Such an opacity causes no symptoms of irritation, and 
does not cause the least disturbance of the healing of the wound. This proves 
that we do not have to do with a real inflammation. Anatomical investigation 
has, in fact, shown that in these cases cellular infiltration is altogether wanting, 
and that there is simply a dilatation of the lymph spaces of the cornea, which are 
distended with fluid (Becker, Laqueur, Recklinghausen). The striate opacities 
themselves are referable to wrinkling of Descemet's membrane, which as a result 
of the incision near the corneal margin has its tension relaxed in one direction, 
but not in others (cf. Fig. 66). 

A wrinkling of this sort may be the cause of many of the striate opacities that 
are observed in conjunction with a true keratitis — e. g., the radiating streaks 
which are often seen in ulcus serpens extending out into the transparent cornea 
(Hess, Schirmer). 

A similar striate opacity of the cornea is sometimes observed in cases of 
detachment of the retina, which have been treated with the pressure bandage. 
The eye becomes suddenly very soft and the anterior chamber remarkably deep, 
and in the cornea fine gray strias show themselves, which cross in different 
directions, so that the opacity looks like creased tissue paper. Here also, 
without doubt, folds in the cornea take part in producing this effect (Deutsch- 
mann, Nuel). 

II. Injueies of the Cornea. 

43. 1. Foreign Bodies in the Cornea.— The penetration of foreign 
bodies into the superficial layers of the cornea is among the most 
common of accidents.' Obviously the interpalpebral area of the cornea 
is the part that suffers most from injuries due to foreign bodies as 
from injuries in general. What is most frequently observed are small 
particles of iron in the cornea, particularly among mechanics of a cer- 
tain sort, like locksmiths, blacksmiths, iron founders, etc. These par- 
ticles do not look like metallic iron, but vary from dark brown to black ; 
for the particles of iron, whicb, for example, fly off when iron is being 
hammered, are heated by the force of the blow so that they are thrown 
out as sparks. Thus they become oxidized into ferroso-ferric oxide (so- 
called iron scale), and under this form are found in the cornea. If the 
fragment of iron remains sticking in the cornea, it becomes surrounded 



DISEASES OP THE CORNEA. I99 

■very soon by a brown ring, because it impregnates the portions of the 
cornea in its immediate vicinity with iron (ferric hydrate) and so turns 
them brown. Fragments of coal are also frequently found in the cor- 
nea — for instance, in firemen or in people after a railroad journey — 
and fragments of stone in stonecutters, stone breakers, etc. 

Foreign bodies penetrating into the cornea should 'be removed as 
soon as possible. If they are superficially situated, it is an easy matter 
to pry them up with a suitable instrument. For this purpose we use 
a special needle, which is made broad at its upper end, or an instrument 
upon the plan of a small gouge. In default of such instruments we 
may also make use of a sharp sewing needle which has been previously 
sterilized by heating in a flame. It is advantageous first to render the 
cornea insensitive by the repeated instillation of a five-per-cent solution 
of cocaine. In the case of fragments of iron, besides the foreign body 
the ring of brown-colored corneal tissue next it should be scraped off. 

If the foreign body is not removed in season, its expulsion by sup- 
puration follows. An inflammatory infiltration forms about it, sur- 
rounding it in the form of a gray ring. Then the tissue of the cornea 
in this place breaks down, so that the foreign body becomes loose and 
ultimately falls out. The resulting ulcer generally becomes rapidly 
cleansed and heals, leaving a small opacity after it. This process of 
elimination takes place with marked symptoms of irritation, and espe- 
cially with hypereemia of the iris, or even with iritis, which latter makes 
itself evident by the formation of a hypopyon and of synechise. It is 
only grains of powder or of lime that are known to have the property of 
remaining in the cornea without exciting suppuration and of becoming 
permanently incorporated in it. 

Much more infrequent, but also much more serious, are those cases 
in which a small foreign body has penetrated into the deep layers of 
the cornea. In this case, in order to remove the foreign body, it is 
often necessary to incise the lamellse of the cornea that lie above it, so 
as to be able to draw it out with the forceps. If the point of the for- 
eign body projects into the anterior chamber there is the danger that, 
in attempting to grasp the foreign body, the latter may be pushed in 
still farther, and may injure with its point the capsule of the lens. In 
such a case, therefore, the indication sometimes is to make a prelimi- 
nary opening in the cornea near its margin and to introduce the in- 
strument from this point into the anterior chamber, by which means 
we press the foreign body from behind forward, so that we can grasp it 
by its anterior extremity and extract it. 

2. Solutions of Continuity of the Cornea.— Superficial excoriations 
of the cornea, which simply produce a loss of substance in the epi- 
thelial covering, are known as erosions. These are among the most 
frequent of injuries, such as one gives himself by scratching the 
eye with the finger nail, with a rough cloth, a stifE leaf or twig, etc. 



200 DISEASES OF THE EYE. 

Sucli an injury is commonly accompanied by pretty marked symptoms 
of irritation, such as photophobia, lachrymation, and especially by vio- 
lent pain. Examination of the eye shows, besides the ciliary injection, 
a defect in the epithelium, forming an ulcer, the floor of which is per- 
fectly transparent, so that it is only by taking the corneal reflex that 
the loss of substance can be discovered. Healing generally takes place 
within a few days by a complete regeneration of the epithelium, start- 
ing from the edges of the epithelial defect; a permanent opacity does 
not remain. Quite a good deal of signiflcance attaches to these trau- 
matic erosions, from the fact that not infrequently they are the start- 
ing-point of an ordinary ulcer of the cornea, or an ulcus serpens, es- 
pecially if an opportunity is given for the production of infection. 
This latter is particularly apt to be the case when a conjunctival trouble 
associated with abnormal conjunctival secretion, or when ablennorrhoea 
of the lachrymal sac, is present. 

It is worth remarking that sometimes recurrences of corneal erosion 
take place without any new injury having preceded them (Arlt). 
After the lesion has been to all appearances fully healed, marked 
symptoms of irritation set in suddenly several weeks or months after- 
ward without known cause ; and a loss of substance is again found upon 
the cornea in the epithelium at the site of the former injury. Such 
relapses may occur repeatedly. They have their cause probably in the 
fact that the epithelium at the original site of injury has never become 
regenerated in a perfectly normal fashion, so that under the action of 
any insignificant cause it is again separated and cast off. It appears 
that this separation of the epithelium generally takes place in the form 
of a vesicle, which, however, ruptures so quickly that we do not get a 
sight of it, but only of the consequent loss of substance in the epithe- 
lium. 

Erosions are best treated by the application of a simple protective 
bandage, the use of which should be kept up until the epithelium is com- 
pletely regenerated. In this measure also is found the best protection 
against relapses ; and if the latter do occur, they require the wearing of 
the bandage a second time, and that, too, for a sufficiently long period. 
If marked symptoms of an accompanying inflammation exist, and these 
are not relieved by the bandage alone, we may instill atropine. 

The deeper luounds of the cornea are usually either incised or lacer- 
ated wounds. Their margins soon after the infliction of the injury be- 
come cloudy and swollen through imbibition of fluid (tears or aqueous). 
In irregular, lacerated wounds, this may occur to a very great extent. 
As the wounds heal the cloudiness of their edges in large part disap- 
pears, although a dense opacity always remains along the line corre- 
sponding to the solution of continuity, and this opacity is very fre- 
quently associated with an irregular bulging of the cornea (giving rise 
to irregular astigmatism). Corneal wounds are particularly dangerous 



DISEASES OF THE CORNEA. 201 

under two circumstances — i. e., when they are infected and when they 
perforate the cornea. In the former case a purulent keratitis develops 
which may give rise to extensive destruction of the cornea. In the 
latter case prolapse of the iris occurs, provided the wound is large 
enough. Moreover, the iris or the lens may be injured at the same 
time, and lastly there exists, as in all perforating lesions of the eyeball, 
the danger of an inflammation of the deep parts of the eye, produced 
by infection, and very frequently ending in the destruction of the 
organ. 

The treatment of recent wounds of the cornea demands as its prime 
requisite that we should strive to prevent infection. We cleanse the 
eye with antiseptic solutions, strew the wound with finely powdered 
iodoform, and, after we have dropped in atropine to combat any iritis 
that may exist, we apply a protective bandage. If we are dealing with 
a perforating wound of the cornea, the greatest possible quiet on the 
part of the patient (rest in bed) is requisite in order to bring about a 
speedy and solid closure of the wound. If the iris is prolapsed, it 
should be so excised, after carefully separating it from the lips of the 
wound, that no iris remains any longer incarcerated in the wound ; 
according to just the same principle that holds good for prolapses of 
the iris of spontaneous origin. (For more precise particulars in regard 
to perforating wounds of the cornea, see §§ 53 and 54.) 

3. Injuries of the Cornea by Caustic Agents and by Burns. — These 
occur simultaneously with the analogous injuries of the conjunctiva, 
and are produced by the same causes that these are (see page 110). In 
fact, in the case of such injuries of the eyeball, it is precisely the part 
which the cornea takes in the process that is a criterion for the prog- 
nosis — for the most harmful consequences of these injuries are the 
opacities which are left in the cornea. The corroded or burned cornea 
looks dull and opaque. The extent of the opacity depends upon the 
extent of the burn, but the intensity of the opacity depends upon the 
depth to which the corneal tissue has been destroyed. In light cases 
the color of the opaque cornea is gray, but in severe cases whitish. In 
the worst cases the cornea is all as white as porcelain, dry upon its sur- 
face, and quite insensitive ; such a cornea is completely necrotic. In 
general it is not always easy to estimate from the character of the in- 
jury alone how deejoly the destructive process has penetrated into the 
cornea, and hence caution is advisable in giving the prognosis. 

The injury is generally followed by sharp pain. It heals by the 
extrusion of the dead tissue. In the lightest cases, in which the injury 
has affected the epithelium only, the processes of extrusion and of heal- 
ing occur very rapidly (as in the frequent cases of burns of the cornea 
produced by a curling iron). If the destructive process has made its 
way into the parenchyma of the cornea, a delimiting suppuration sets 
in, which leads to the separation of the eschar ; the loss of substance 



202 DISEASES OF THE BYE. 

thus produced heals, leaving a permanent opacity. If the destructive 
process has at any point gone through the entire thickness of the cor- 
nea, perforation of the latter develops after the separation of the eschar. 
The iris then prolapses, and the resulting cicatrization unites the iris 
to the cornea (cicatrix of the cornea v?ith anterior synechia). In a 
similar way adhesions often develop between the cornea and the con- 
junctiva of the lids (symblepharon), provided that a loss of substance 
is present in the latter also. The treatment of injuries produced by 
burns and caustics has already received mention under the head of the 
analogous injuries of the conjunctiva. 

Contusions of the cornea, produced by force applied to the latter either di- 
rectly or through the lids, often result in an extensive opacity which occupies the 
central portions of the cornea, and under the magnifying glass can be resolved 
into delicate gray striae interlacing in different directions. As this opacity is 
situated in the intermediate and the deep layers of the cornea, it has been con- 
sidered under the head of keratitis profunda (page 194). The striae may in 
part be referable to wrinkling of Descemet's membrane, and be dependent upon 
the reduction in the intra-ocular pressure that often occurs after contusions 
of the cornea (see § 86). 

Severe contusions of the cornea may cause its rupture (ruptura cornese). 
Such ruptures are much less commonly observed than are those of the sclera. 
Moreover, while ruptures of the sclera are generally pretty much alike in respect 
to position and direction (see § 53), ruptures of the cornea follow no rule with 
regard to the way they run. In most cases the wounds are nearly rectilinear, 
but sometimes they look jagged, and are flap-shaped. Most of the cases of 
rupture of the cornea that I have seen were the result of blows from a whip- 
lash, and these generally in young people. If the edges of the wounds gape 
widely, as is especially the case in flap wounds, we may make the attempt to 
unite them by fine, superficially disposed sutures. Sometimes it is possible in 
this way to save the eye, although such marked flattening and opacity of the 
cornea always remain that the visual power is reduced to a minimum. 

The healing of incised wounds of the cornea takes place quickly, when, as is 
pre-eminently the case in operation wounds, the edges are smooth and are 
closely applied to each other. The edges of the wound then soon become ag- 
glutinated by a mass which consists of fibrin and round cells, and which later 
organizes into a delicate cicatrix binding the corneal lamellee together. Bow- 
man's and Descemet's membranes do not reunite. During the first few days 
the epithelium of the anterior surface of the cornea grows rapidly over the lips 
of the wound and down between them ; this involution of the epithelium some- 
times extending as far as the posterior layers of the cornea. By reason of the 
permanent adhesion of the lips of the wound that takes place later, the intrud- 
ing epithelium is gradually squeezed back from below up toward the surface, 
and the epithelial involution disappears. Sometimes, however, it is persistent. 
In that case the wound externally looks as though it had healed smoothly, 
while really only the posterior layers of the cornea are united by a firm cicatrix. 
Such scars may be ruptured by moderate pressure upon them ; and this explains 
why it is that the scar left by a cataract operation sometimes — it may be years 
afterward — splits asunder on very slight provocation. 



DISEASES OP THE CORNEA. 203 



III. Opacities of the Coenea. 

44. Opacity of the cornea is a constant accompaniment of every 
inflammation bf the latter. This recent inflammatory opacity is of a 
changeable nature, increasing or diminishing according to the course 
of the inflammation. From this variety we must' distinguish those 
opacities v?hich are stationary, whether they represent the residua of 
an inflammation that has already run its course, or have developed 
gradually without any antecedent inflammation. These stationary 
opacities, of which alone we shall treat here, we call opacities of the 
cornea in the narrower sense of the word. They are by far the most 
frequent cause of poor sight, and hence have a particular claim upon 
the interest of the physician. 

We distinguish stationary opacities of the cornea into those of in- 
flammatory origin and those which have developed without any ante- 
cedent inflammation. 

Opacities of the cornea of inflammatory origin are the consequence 
of a keratitis, either suppurative or non-suppurative. In the first case 
the tissue of the cornea, which has been destroyed by suppuration, is 
replaced by cicatricial tissue, and the opacities thereby produced are 
corneal cicatrices in the proper sense of the word. In this category 
also are to be counted most opacities which remain after injuries. The 
cornea may also have opacities remaining after a non-suppurative 
keratitis, either because its tissue has been so altered by the deposition 
of exudate which has taken place that it does not even afterward regain 
its physiological transparency, or because the exudate itself in part be- 
comes organized and thus remains as new tissue in the cornea (an ex- 
ample is a pannus which has been transformed into connective tissue). 
Opacities that are situated in the epithelium only are comparatively 
rare, occurring, for instance, in those cases in which the epithelium 
as a result of constant mechanical irritation — in trichiasis — becomes 
thickened and hence opaque. 

The appearcmce of opacities of the cornea varies according to their 
degree of intensity and their age. Slight opacities appear as trans- 
lucent bluish-white spots with outlines altogether hazy — rdaculm or 
mileculcB cornecB. Well-marked opacities are grayish-white or pure 
white, and are usually pretty sharply outlined ; moreover, in the begin- 
ning they are apt to be traversed by vessels which afterward become 
fewer or disappear altogether. The surface of the opacity generally 
lies on a level with the adjacent healthy cornea, especially if the opaci- 
ties are small, although elevation or depression of the surface of the 
cornea at the site of the cicatrix is also observed. Elevation of the 
surface is commonly the result of an ectasis of the cicatrix. More 
rarely it is caused by excessive development of cicatricial tissue, or by 
thickening of the epithelium upon the surface of the cicatrix. De- 



204 DISEASES OF THE EYE. 

pression of the surface of the cornea at the site of the cicatrix occurs 
most frequently in the case of small cicatrices from the incomijlete 
filling up of the ulcer with cicatricial tissue {facet of the cor?iea). In 
the case of larger cicatrices that have developed in consequence of 
extensive perforation of the cornea, or more rarely as a result of a severe 
non-purulent keratitis, a flattening of the entire cornea may follow 
from the retraction of the cicatricial tissue {applanatio cornece). This 
is especially apt to occur if a plastic irido-cyclitis had existed simul- 
taneously with the inflammation of the cornea ; for, on account of this 
irido-cyclitis, extensive membranous exudates are deposited in the in- 
terior of the eye, which by their contraction diminish the intra-ocular 
pressure, and so favor the flattening of the cornea. 

With many cicatrices incarceration of the iris occurs. This is a 
proof that there has been an antecedent perforatioii of the cornea ; 
hence such cicatrices are always very thick. It is important to deter- 
mine in any special case whether a cicatrix of the cornea is or is not 
connected with the iris, since an incarceration of the iris may entail 
serious consequences. We recognize the presence of such an anterior 
synechia by the displacement of the pupil toward the site of the in- 
carceration, and furthermore by the unequal depth of the anterior 
chamber, which is always shallower near the place where the iris is 
adherent. In many cases, also, the dark color of the cicatrix gives 
evidence of the incarcerated iris, the pigment of which shows through 
the cicatricial tissue. The union between iris and cicatrix is often 
confined to quite a small spot, so small, sometimes, that only a very fine 
filament rises from the iris and passes over to the cicatrix in the cornea. 
At other times broad adhesions exist, and there may even be an incar- 
ceration of the entire pupillary margin of the iris in the cicatrix. In 
this case occlusio and seclusio pupillai are produced, with their baneful 
consequences (see § 68). 

45. Disturbance of Vision produced by Opacities of the Cornea.— 
Every opacity which falls wholly or in part within the pupillary region 
of the cornea results in disturbance of vision; for the sum of the 
incident rays at the site of the opacity, instead of being all permitted 
to pass through the cornea, is divided into two parts : one part is 
absorbed by the cicatrix or is reflected off from it ; the other part pene- 
trates through it into the eye. The relation between these two parts 
. depends upon the density of the opacity ; the denser it is, the more 
numerous are the reflected, the less numerous the transmitted, rays. 
Hence the cicatrix does harm by cutting off light. To bo sure, tliis 
factor becomes a matter of serious consideration only in ^■cry dense 
opacities, since we are able to see with very mucli less liglit than we 
usually get. Thus we see through a stenopaeic slit scarcely less clearly 

— and if affected with an error of refraction even more clearly (§ 139) 

than with the naked eye, although the slit allows but little light to pass. 



DISEASES OF THE CORNEA. 205 

So, also, people with abnormally contracted pupils are still able to see 
with perfect distinctness. The real cause of the disturbance of vision 
produced by corneal opacities is not, therefore, the cutting off of light, 
but rather the scatter my {diffi(sion) of light. For, rays passing through 
a turbid medium, such as a cloudy cornea, are not regularly refracted, 
but are scattered in all directions, just as if they emanated from the 
turbid stratum itself. Thus, when a physicist requires a uniform illu- 
mination, he makes the light from a luminous body pass through a 
ground-glass plate or through oiled paper, substances which may then 
be considered to act as self-luminous bodies themselves. The diffusion 
of the rays is the more complete the denser the opacity. 

With respect to the density and the extent of the opacity, the fol- 
lowing cases are possible : 1. A dense opacity occupies the whole pupil- 
lary region of the cornea. Then all the light that issues through the 
scar is diffused ; no image at all of external objects is formed upon the 
retina, and therefore there can not be qualitative but only quantitative 
vision. 2. A slight opacity covers the whole pupillary area. In this 
case the diffusion of light is not complete. A part of the rays is re- 
fracted, although not quite regularly ; another part is diffused. Hence 
there are retinal images formed, which are, however, indistinct ; and, 
besides, there is much diffused light. 3. Only a part of the pupillary 
region is taken up by the opacity, while the remaining part is normally 
transparent. Then distinct retinal images are produced by means of 
the latter clear portion, but at the same time mucli dillused liL;lit is 
thrown into the interior of the eye by means of the clouded poriion. 
Hence in this case also vision is disturbed, and that by the dazzling 
which the diffused light causes. 

To the disturbance of visioji produced by diffusion there is often 
added that caused by the irregular curvature of tlio corneal suii'ace, 
which is so often present at the site of opacity. There is thus pro- 
duced that refractive condition which is designated by the name of 
irregular astigmatism (see § 148). If the opacity of the cornea corre- 
sponds to a flattening of the surface, as in facets of the cornea, this 
spot refracts less strongly and is hypermetropic ; if the cornea is bulged 
forward at the site of the opacity, as in the case of ectasise, excessive 
refraction, and with it myopia, are produced. In ectatic cicatrices of 
the cornea the abnormality of curvature is not confined to the cicatrix, 
but extends to the neighboring transparent portion of the cornea also, 
so that, as a rule, no portion of the cornea retains its normal curvature. 
In consequence of the irregular astigmatism, objects appear indistinct, 
distorted, and often also double or multiple. 

The disturbance of vision produced by an opacity of the coi'nea 
often entails still other indirect results. Among these are strabismus, 
nystagmus, and myopia. The last named is in many cases only appar- 
ent. The patient with corneal opacities brings minute objects unusu- 



206 DISEASES OF THE EYE. 

ally close to his eye, in order to make their retinal images as large as 
possible, and so in a measure compensate for their indistinctness. 
Nevertheless, elongation of the axis of the eye — i. e., true myopia — may 
ultimately develop in consequence of the great accommodation and 
convergence necessitated through such an excessive approximation of 
objects. 

Treatment. — The chief task that this has to attend to is to improve 
the sight. The means employed for this purpose are as follows : 

(«) Clearing up of the Opacity. — In the case of every opacity of 
recent date we must first try to clear it up as much as possible by the 
application of irritants (see page 157). 

In older opacities, which can not be cleared up any further by me- 
dicinal means, the next step apparently would be to render the cornea 
transparent once more by excising the opaque layers with the knife. 
Such attempts, however, have resulted unsuccessfully, for the loss of 
substance resulting from the excision of the opacity heals again with 
the formation of cicatricial tissue — that is, with the formation of an 
opacity, just as before. Removal of opacities by operation is only in- 
dicated when they are situated in the epithelium, since losses of epi- 
thelium are made good by normal transparent ejDithelium. Cases in 
which removal of the epithelium — airasio cornece^ — is indicated, are 
those in which the epithelium has been thickened by mechanical irrita- 
tion, as in trichiasis ; also in those in which lead, lime, or grains of 
powder are imbedded in the epithelium. 

In cases in which the cornea is cicatricial throughout, the attempt 
has been made to restore the sight by transplantation of the cornea. 
A circular piece is excised by means of a small trephine from the 
opaque cornea, and an equally large piece of a normally transparent 
cornea (from the eye of a human being or of an animal) is inserted in the 
opening. The transplanted piece of cornea unites, as a rule, but after- 
ward becomes opaque, and completely so for the most part, so that 
the patient gains nothing. 

(b) The optical aids that may be employed for improving the sight 
are glasses and the stenopaeic aperture. The object of the latter is to 
bring nothing but the transparent part of the cornea into use for vision, 
and to exclude the portion bearing the opacity, by which means the 
dazzling due to diffusion is prevented. Glasses may sometimes be of 
advantage when the opacity is complicated with changes in the curva- 
ture of the cornea. 

(e) Displacement of the pupil by means of iridectomy (after the 
method of Beer) is generally the only means of restoring sight in the 
case of dense opacities which entirely conceal the pupil. (For the indi- 
cations and the method of performing this operation, see the section on 
operations, § 155.) 

In large and very white cicatrices of the cornea it is often desirable 



DISEASES OP THE CORNEA. 207 

to do away with the disfigurement that they produce. For accomplish- 
ing this purpose, tattooing of the cornea (De Wecker) is of service. 
This procedure depends upon tlie observation that many bodies, as, for 
example, grains of powder, may become imbedded in the cornea and 
remain there permanently. Tattooing consists in giving the white cica- 
trix a black tint by means of India ink, which is introduced into the 
cicatricial tissue by being repeatedly pricked in with a needle. The 
tattooing needles used for this purpose consist either of a bundle of 
ordinary sharp-pointed needles (Taylor), or of a single broad needle 
which is channeled for the reception of the ink (grooved needle of De 
Wecker). 

Prom the form and position of corneal opacities we may often gather an 
impression as to the variety of keratitis to which they owe their origin. Thus : 

(a) Maculse of the cornea originate from small corneal ulcers. They most 
frequently develop in childhood as a consequence of conjunctivitis eczematosa, 
and in that case are often distinguished by being situated on the margin of the 
cornea. Quite characteristic opacities are the elongated ones that are left by 
a vascular fasciculus. 

(J) Opacities which are thin and diffused, but which are nevertheless 
spread over the greater part of the cornea, are mostly the result of pannus or 
of parenchymatous keratitis. Opacities resulting from pannus are situated 
superficially, while those due to parenchymatous keratitis are situated in the 
depth of the cornea, and when examined with the magnifying glass disclose, 
even years after the inflammation has ceased, the presence of deep-seated vessels. 

(c) Extensive, tendinous-looking opacities, without incarceration of the iris, 
in which chalky-white dots are often visible, are observed after particularly 
severe cases of parenchymatous keratitis. Similar white dots also occur some- 
times in the opacities due to pannus (see page 83) ; also in those resulting from 
corrosion by lime, in this case depending upon imbedded calcareous particles. 
Finally, cicatrices with incrustation of lead are also distinguished by a sharply 
circumscribed, extremely white opacity. 

{d) Marginal, crescentic, or arcuate opacities are the consequence of ca- 
tarrhal ulcers or of keratitis marginalis ; they should not be confounded with 
an arcus senilis. 

(e) Marginal scars with incarceration of the iris form after perforating ulcers 
in conjunctivitis eczematosa. They are round, often consisting of a thinner, 
dark center (the incarcerated iris) surrounded by a white cicatricial ring. They 
lie so far peripherally as often to extend into the limbus, and on account of this 
peripheral situation are associated with a particularly marked displacement of 
the pupil. 

(/) Large, dense cicatrices with inclusion of the iris, which often occupy 
the whole cornea except a narrow rim about the margin, are most frequently 
produced by an ulcus serpens or by acute blennorrhosa. The same sort of ex- 
tensive cicatrices also occur after keratomalacia, diphtheria, and burns ; in the 
last two cases cicatrices upon the conjunctiva are never wanting, and conduce 
to the correct diagnosis. 

{g) Sharply defined punctate or striate cicatrices are the result of trauma- 
tism, whether effected by accident or by design (operation). 



208 DISEASES OF THE EYE. 

(h) Dense, white cicatrices, which occupy the lowermost part of the cornea 
and terminate above in an almost horizontal border, are caused by keratitis e 
lagophthalmo. Sometimes we see men in whom such cicatrices are present in 
botli eyes. In this c::se the cicatrices are usually the consequence of some severe 
disease, in which a condition of somnolence and a resulting imperfect closure 
of the lids were present and lasted for some time. 

(i) Opacities in the lowermost part of the cornea having the shape of a 
triangle with its apex directed upward are the result of a parenchymatous kera- 
titis which, contrary to rule, has become localized in the lower half of the 
cornea, or are due to the deposition of an exudate upon the posterior corneal 
surface. 

(j) Small, bluish-white opacities which are situated at the margin of the 
cornea and project into the transparent part of it under the form of obtuse- 
angled triangles, are the residua of a sclerosing keratitis. 

A peculiar sort of opacity is that which develops when the anterior chamber 
remains for some time filled with blood. Then the cornea takes on an intense 
reddish, brownish, or brownish-green color, and at the same time becomes so 
opaque that the parts beneath can no longer be distinguished through it. It 
gradually clears again, beginning at the edge, but only in rare cases becomes 
once more perfectly transparent, and then only after months or years have 
elapsed. In that stage in which the central brown portion is surroimded by a 
narrow marginal zone which has regained its transparency, it looks as if a 
brown-colored crystalline lens had prolapsed into the anterior chamber and was 
lying behind the cornea. The coloration of the cornea in this case is due to the 
fact that the blood coloring matter being dissolved by diffusion penetrates into 
the cornea and is deposited there under the form of crystals of hsematoidin 
(Vossius, Treacher Collins, etc.). 

Opacities that are produced by the deposition of an exudate sometimes ex- 
hibit an adhesion of the iris to the cornea, and hence belong to those rare 
cases in which an anterior synechia exists icithout a preliminary perforation of the 
cornea. The iris is drawn up to the posterior surface of Ihe cornea by the exu- 
date, while it is contracting and undergoing organization, and becomes fixed 
there. In a similar way antei'ior synechia without preliminary perforation of 
the cornea is observed in those cases in which the iris has been pushed forward 
as far as the posterior surface of the cornea and kept there for some time. The 
iris in such cases becomes agglutinated to the cornea in spots, and if it afterward, 
either spontaneously or as the result of an iridectomy, returns to its normal 
position, these agglutinated parts of it remain attached to the cornea. We then 
either find the iris extensively adherent to the cornea, or one or two tags arise 
from it, whose apices are inserted into the posterior corneal surface. The same 
thing may take place if the anterior chamber has been effaced for some length 
of time, so that iris and cornea have been directly in contact with each other. 

Cicatrices of the cornea often undergo subsequent metamorpTioaes. It 
often happens that delicate cicatrices dating from childhood no longer appear 
in adult life under the guise of a continuous opacity, but are traversed by 
clear strise, interlacing in all directions and thus dividing the opacity into 
small separate areas. This peculiar aspect of an opacity always indicates that 
the latter has lasted a very long time. The explanation of it probably is that 
In the interstitial growth of the cornea new-formed transparent fibers develop 
between the old opaque ones. It may also happen that cicatrices, originally 



DISEASES OF THE CORNEA. 209 

flat, later become ectatic. Markedly eetatic cicatrices, the most prominent point 
of whichisbut incompletely covered by the lids, not infrequently display at this 
point a xerotic condition of the epithelium, which looks dry and epidermoid. 
In old, dense cicatrices, yellow spots sometimes develop, caused by the deposi- 
tion of concretions of a hyaline or amyloid substance. Small, chalky-white 
specks imbedded in the cicatrix are to be referred to a deposition of lime. In 
fact, small calcareous plates are frequently thus formed, which, when they be- 
come loose, can be picked off with a forceps. In these cases we have to do 
with different varieties of retrograde metamorphosis, which are referable to an 
insufficiency of nutrition of the dense cicatricial tissue. Such processes may 
give rise to the softening and ulcerative disintegration of old cicatrices — so- 
called atheromatous ulcers, which not infrequently induce perforation. 

CoBNEAL Opacities of Non-inflammatoet Origin. — These are mostly 
referable to a lowering of the nutrition of the cornea. The typical example of 
a physiological non-inflammatory opacity, which appears in the cornea of sound 
eyes in advanced life, is the amis senilis (gerontoxon cornese), which has been 
described in speaking of the anatomy of the cornea. The arcus senilis is 
formed by the deposition of hyaline masses and minute particles of lime in the 
more superficial layers of the cornea, close to the limbus; its cause is assumed 
to be senile atrophy of the limbus, with involution of a portion of the vascular 
loops contained in it. 

Opacities resembling the arcus senilis are also found in conjunction with 
other affections of the limbus — e. g., with the growths of vernal catarrh, with 
small neoplasms, and sometimes even with a large pinguecula. 

Among pathological opacities of non-inflammatory origin the principal one 
requiring mention is the zonular opacity of the cornea.* This forms a gray stripe 
from three to five millimetres broad, which passes straight across the cornea, a 
little below its center. It develops with extreme slowness, occupying years in 
its progress ; the first parts to appear being the two terminal points of the 
opaque stripe — that is, the portions of the opacity lying nearest the outer and 
inner margins of the cornea. These points are always .separated from the margin 
of the cornea by a narrow, transparent zone. Starting from them the opacity 
gradually pushes its way toward the middle line, where the two parts of it 
unite, and thus close in the opaque zone which covers the lower half of the 
cornea. This zone is, accordingly, broadest and most opaque at its two extrem- 
ities, these being its oldest parts (Pig. 57). On examining it pretty closely, es- 
pecially with a magnifying glass, we ascertain that the opacity, which has a 
sharply defined outline on all sides, is composed of minute white or gray dots 
which lie quite superficially in the epithelium or directly beneath it ; hence we 
usually find the surface of the cornea over the opacity roughened like shagreen 
or covered with minute prominences. 

Zonular opacity of the cornea generally develops in eyes which have nearly 
or quite lost their sight in consequence of some intra-ocular affection (irido- 
cyclitis, glaucoma), and in this case it is practically of little significance. It is 
only very rarely (and then only in elderly people) that we encounter it in eyes 
which are otherwise perfectly sound, so that here the corneal opacity itself is 
the sole cause of the disturbance of vision (senile zonular opacity). 

The anatomical changes that are the fundamental factors in producing zonu- 

* Synonym : Ribbon-shaped opacity of the cornea. 
14 




210 DISEASES OP THE EYE. 

lar opacity of the cornea consist in the deposition of hyaline masses and of lime 
in the epithelium and in the uppermost lamellse of the cornea. 

Zonular opacity of the cornea depends upon a disturbance of nutrition, 
caused by a lessened ability on the part of the cornea to withstand external in- 
jurious influences. The position and extent of the opac- 
ity correspond to the palpebral zone of the cornea — i. e., 
that part of it which lies exposed in the palpebral Assure 
even when the latter is but slightly opened. Since this 
form of opacity affects cornese which have generally been 
made insensitive already and often opaque, too, by some 
antecedent disease, it must be assumed that it occurs be- 
cause these corneaa are unable any longer to withstand 

^ ,, _ . properly the external injurious influences to which thev 

Fig. B7.— Zoktjlar Opac- f i J . , , 

iTY OF THE Cornea. ^^^ subjected m the region of the palpebral fissure. If 
such influences exert their effect for a very long time, 
even healthy cornese may react to them by the production of a zonular opacity. 
Thus Topalanski has seen this opacity in three hat makers, into whose eyes 
particles of hair were constantly flying from the hare's skins that they were 
engaged in cutting. I myself found zonular opacities of both eyes in a physi- 
cian who had blown calomel into them every day for twelve years. According 
to Leber, one of the injurious influences that affect the palpebral region of the 
cornea is evaporation : the nutrient fluid of the cornea being supposed to be 
richer in lime salts in cases of zonular opacity, and these salts being precipi- 
tated under the influence of evaporation. 

The zonular opacity being superficially placed, it can readily be removed by 
scraping off the epithelium and the cloudy corneal layers immediately subjacent 
(abrasio corneee). There is, of course, no object in doing this except in the cases 
where, as in the senile form, we have to do with an eye that but for the opacity 
would be serviceable for vision. 

Among the varieties of opacity which do not depend upon inflammation, be- 
long also the pressure opacity of the cornea— i. e., that form of opacity which 
develops in connection with an elevation of the intra-ocular tension. It is a 
diffuse, smoky opacity, which is most marked in the center of the cornea and 
gradually diminishes toward its margin. That it is not of inflammatory nature 
is proved by the fact that, after the disappearance of the rise in tension, it very 
soon, often in less than an hour, vanishes completely, which would not be pos- 
sible if it depended upon an inflammatory infiltration of the cornea. In fact, in 
the case of the pressure opacity we are dealing simply with an oedema of the 
cornea, which is situated mainly in the epithelium, and which is capable of rapid 
subsidence (see Fig. 37). 

Likewise of non-inflammatory origin is the traumatic striate opacity of the 
cornea (page 198). 

Congenital opacities of the cornea, although rare, do occur, some being of in- 
flammatory, some of non-inflammatory, origin. The' former are caused by a 
fffital keratitis. The latter are relatively more frequent, and are found in con- 
junction with other congenital anomalies of the eye. Enihryontoxon is the name 
given to a congenital opacity which in shape and appearance is similar to a ger- 
ontoxon. 

The disturbance of vision hy dazzling, which occurs when an opacity is 
present in the pupillary region of the cornea, is explained as follows : In the 



DISEASES OF THE CORNEA. 2U 

normal eye the images of the objects in the visual field lie upon the retina, side 
by side and sharply separated from each other, the bright and dark parts in 
contrast. Now, if by means of a spot of opacity upon the cornea light is dif- 
fused uniformly over the whole retina, the distinction between the light and 
dark portions of the retinal images becomes less striking. The following com- 
parison may illustrate these conditions : In a well-taken photograph all details 
are seen sharply and distinctly. But if it is rather highly glazed, and we look 
at it obliquely, the glazing shines so that the details of the photograph can no 
longer be distinguished. As the glazing is perfectly transparent, the rays 
emanating from the photograph still arrive at our retina and produce there 
sharp images of the details of the photograph. But in addition there come 
numerous rays reflected from the surface of the glazing, which so flood 
the whole retina with light that the sharp retinal images are, so to speak, 
drowned out. 

A man with sound eyes can get an idea of the sensation of dazzling pro- 
duced by corneal opacities, if, when in a picture gallery, he looks at a picture 
which is hung upon a narrow strip of wall lying between two windows. He 
can scarcely see what the picture represents, and has a very unpleasant sense of 
dazzling. How is the difiusion of light efiected in this case? The normal cor- 
nea is not, as is ordinarily assumed, absolutely transparent. We can see this 
from the fact that a portion of the cornea, which has light concentrated upon it 
by focal illumination, looks gray, insomuch that the tyro might suppose that 
there was a pathological opacity of the cornea. The cornea, therefore, always 
reflects a certain quantity of light. The like is true of the lens, and, generally, 
of all the refracting media of the eye. In consequence of this imperfect trans- 
parency of the refracting media, diSusion of light takes place even in the nor- 
mal eye, although, to be sure, under ordinary circumstances, it is too incon- 
siderable to excite notice. But, in the example given, diflfusion exerts such 
a disturbing eSect, because, in proportion to the light reflected from the 
picture, an uncommonly large amount enters the eye from the two windows, 
and thus a comparatively large quantity of light undergoes difiusion over the 
retina. 

For clearing up old opacities, especially those produced by parenchymatous 
keratitis, electricity has done me good service in some cases. The positive pole 
of a constant-current battery is placed on the temple or the neck, while the 
negative pole is applied to the previously cocainized cornea. The negative pole 
consists of a solid cylinder of silver, 7 mm. in diameter. This is surrounded by 
an insulating envelope of caoutchouc, the only portion exposed being the sur- 
face at its end, which is concave so as to fit the surface of the cornea. Contact 
between the electrode and the cornea is effected by a drop of mercury, which 
readily adheres to the concave surface of the silver. The current intensity 
employed is 0.3 to 0.5 milliampSres (Alleman). 

Tattooing should be applied only in the older cicatrices, which are solid and 
flat. For in thin or ectatic cicatrices, the latter may be weakened by the in- 
flammatory reaction, which always follows tattooing, and thus an increase of the 
ectasis or even an elevation of tension may be set up. Nor is tattooing a proper 
procedure for eyes that have been through a severe attack of irido-cyclitis, 
since this disease might be lighted up again by the operation. If we have a 
pretty large scar to tattoo, it is advisable to divide the operation among several 
sittings, so as not to allow the inflammatory reaction to get too great. In the 



212 DISEASES OP THE EYE. 

course of years the black color fades somewhat and requires to be renewed by a 
repetition of the operation. 

In cases in which only a part of the pupillary area of the cornea is opaque, 
and the rest is transparent, tattooing the opaque portion may actually improve 
the sight, since the cicatrix, being made less transparent, does not produce as 
much diffusion of light as before. 

IV. Ectasia ob the Coenea. 

Just as in the case of opacities, so also in the case of ectasise of the 
cornea, we must first of all distin-guish whether they have been pro- 
duced by inflammation or not. On the basis of this distinction we 
make the following subdivision of ectasise of the cornea : 

^ . . ■ r, , ■ ■ ( Staphyloma, 

Ectasise of inflammatory origin . . J B;e,^tectasia. 

^ , . . . „ . • • ( Keratoconus, 

Ectasise of non-inflammatory origin -j „ fib 

1. Staphyloma of the Cornea. 

46. Symptoms. — A staphyloma is a protuberant cicatrix originating 
in a prolapse of the iris, and wholly or in part replacing the cornea. 
We distinguish accordingly between total and partial staphylomata. 
In total staphyloma there is found in place of the cornea an opaque, 
protuberant cicatrix, the base of which is encircled by the margin of 
the sclera or by the very outermost rim of the cornea, which may still 
be preserved. In one series of cases the protuberant cornea has the 
form of a cone (staphyloma tot.ale conicum). In conical staphyloma 
the protuberance starting from the margin of the sclera slopes gradu- 
ally up to its apex (Fig. 63). In other cases, however, the protuber- 
ance is hemispheridal (staphyloma totale sphsericum), and its walls, 
rising abruptly from the sclera or even overhanging it, are sharply de- 
marcated from the latter (Fig. 58). The spherical is more frequent 
than the conical form in total staphyloma. Many spherical staphylo- 
mata, above all those of recent date, have such a very thin wall that 
the layer of black pigment (Pig. 59, i) on its posterior surface is seen 
through it, shining with a bluish luster. Such staphylomata accord- 
ingly form a slate-colored or bluish-black hemisphere, which in form 
and color has a certain resemblance to a blue grape, whence the name 
staphyloma (o-toc^vX^, a bunch of grapes). Afterward thickening of 
the wall of the staphyloma occurs. If this takes place first under the 
form of separate, stout bands, by which the surface of the staphyloma 
is constricted in spots somewhat after the fashion of a blackberry, what 
is called staphyloma racemosum is produced. Old staphylomata have 
for the most part a thick white wall, in which usually one or two dark 
spots may be observed, resulting either from a deposition oi pigment 



DISEASES OF THE CORNEA. 



213 




Fig. 58.— Total Prolapse of the Ibis. 




or from localized thinning (Fig. 59, a). Staphylomata are generally 
traversed by one or two pretty large vessels originating from the con- 
junctiva. On account of the opaqueness of the staphyloma, nothing is 
to be seen of the deeper parts 
of the eye. The iris is all 
taken up into the staphylo- 
ma — that is, all of it except 
its extreme periphery, which 
is so closely applied to the 
posterior surface of what re- 
mains of the marginal por- 
tion of the cornea that there 
is no longer any anterior 
chamber. 

A partial staphyloma oc- 
cupies only a portion of the 
cornea. It rises as a white 
prominence, usually in the 
form of a cone (staphyloma 
partiale conicum) ; spheri- 
cal protuberances (staphylo- 
ma partiale sphEericum) are 
pretty rare'in the case of par- 
tial staphylomata. The re- 
lation here, therefore, is the 
reverse of what it is in the 
case of total staphylomata. 
Partial staphyloma usually 
extends in one direction as 
far as the margin of the cor- 
nea, while in the other direc- 
tion there is a portion of 
the cornea of varying extent 
which is still left, and which, 
moreover, is generally trans- 
parent, so that the iris can 
be recognized behind it. The 
iris is drawn forward to the staphyloma, so that the pupil is displaced 
toward the latter and often partly concealed by it. Indeed, the pupil may 
be closed up altogether if the whole pupillary margin of the iris is incor- 
porated in the staphyloma (as is the rule in the case of total staphyloma). 

Etiology. — Staphyloma constitutes the final outcome of the corneal 
ulcer with perforation, and is nothing but the prolapsed iris which has 
become protruded and transformed into cicatricial tissue. The pro- 
trusion may be primary or secondary in its development. 



Fig. 59. — Total Staphyloma op the Cornea with Con- 
secutive Elevation of Tension, originating from 
THE Total Prolapse of the Iris represented in 
Fig. 58. 

Out of the iris, i (Fig. 58), which has been thinned out 
in consequence of its protrusion, a thicl? cicatrix, iV, 
has ^rown, in which a thin spot, a, corresponds to 
what was once the pupil (jo. Fig. 58), while on the 
posterior surface of the cicatrix the retinal pigment 
of the iris remains as a black coating, i. The 
staphyloma is apparently directly continuous with 
the sclera, S, from which it is separated only by 
Schlemm's canal, s. For, on account of the eleva- 
tion of tension, tlie periphery of the iris has been 
pressed against the cornea so that the anterior 
chamber {v. Fig. 58) has disappeared, and the iris 
and the marginal portions of the cornea are fused 
into a single mass which has been incorporated in 
the staphyloma. As a comparison of the two figures 
shows, the limits of the corneo-scleral margin have 
been enlarged. Because of this, and also because 
of the shrinking of the lens. X, the zonula has be- 
come tightly stretched, and has drawn the atrophic 
ciliary processes, c, inward. The lens is catarac- 
tous, shrunken, and has at its anterior pole a pyra- 
midal cataract, p. 



214 DISEASES OP THE EYE. 

(a) A primary proti'usion is produced in the following way : After 
perforation of the cornea has occurred, the iris becomes prolapsed and 
bulges forward. The cicatrization which follows, and which in favor- 
able cases produces flattening of the prolapse, can not in unfavorable 
cases do away with the protrusion. On the contrary, the prolapsed 
iris remains protruded at the same time that it is gradually con- 
verted into cicatricial tissue ; it becomes consolidated while still in 
a position of protrusion (thus from the prolapse of iris in Fig. 58 is 
formed the staphyloma represented in Fig. 59). A total or partial 
staphyloma develops according as a total or partial prolapse of the iris 
has existed. The causes which oppose the conversion of a prolapse of 
the iris into a flat cicatrix and favor the formation of a staphyloma are 
chiefly two : The first is large size of the perforation. In very small 
perforations there is no development whatever of staphyloma; and 
the larger the perforation, the more likely is it that a staphyloma will 
develop. The second cause is improper behavior on the part of the 
patient. In this regard the chief factors to be considered are, in adults, 
great physical exertion ; in children, crying, and also squeezing to- 
gether of the lids ; and, in both, great straining at stool. The tempo- 
rary increase of tension induced by this means distends the newly formed 
and yielding cicatricial tissue ; but as the latter has no elasticity, it does 
not return to its former dimensions after the elevation of tension has dis- 
appeared, but remains permanently protruded. 

{b) We speak of a secondary protrusion when a prolapse of the iris 
at first heals with the formation of a flat cicatrix, which latter after- 
ward bulges out again. The cause of this is frequently supplied by 
the same injurious influences that have been enumerated above — e. g., 
by the too early resumption of work by a patient with a recently cica- 
trized corneal ulcer. The recent cicatrix is still too yielding to offer a 
proper resistance to the repeated though transitory elevations of intra- 
ocular pressure, and so becomes gradually distended. But in any case 
a protrusion is sure to occur whenever the entire pupillary border of 
the iris is incorporated in the fresh cicatrix. Then, in consequence of 
the shutting off of the anterior from the posterior chamber (seclusio 
pupilte), increase of tension sets in which produces bulging of the 
yielding scar tissue (Figs. 60-63). 

A staphyloma, accordingly, in its origin is not a bulging of the 
corneal tissue, but of the, iris. It develops from a prolapse of the 
iris, which is converted into cicatricial tissue — that is, it develops just 
at the spot where the cornea no longer exists. It would therefore 
be more correct to speak of staphyloma iridis. In fact, the transi- 
tion from prolapse of iris to staphyloma is altogether gradual, so 
that at a certain stage of its development the protrusion in the eye 
may be equally well denoted as an old prolapse of the iris or as a 
recent staphyloma. 



DISEASES OF THE CORNEA. 215 

Consequences of Staphyloma of the Cornea,— The sight is always 
diminished. In total staphyloma it is reduced to the mere ability to 
distinguish between light and darkness. In partial staphyloma the de- 
gree of sight depends upon the character of the part of the cornea that 
is still preserved, and also upon the position of the pupil. Even in 
the most favorable case, in which a part of the pupil happens still to lie 
behind perfectly transparent cornea, the sight is considerably reduced 
by the irregular curvature which is present not only at the site of the 
staphyloma itself, but to a less degree over the whole cornea. Large 
staphylomata produce a very conspicuous disfigurement. They also 
cause trouble by giving rise through mechanical irritation to catarrhal 
conditions of the conjunctiva, with increased secretion, lachrymation, 
etc. The closure of the lids is rendered difficult in the case of large 
staphylomata by the great size of the protrusion ; the apex of the lat- 
ter, being but incompletely covered by the lids, becomes dry (xerotic), 
or becomes the site of ulcers (atheromatous ulcers). Sometimes the 
lids are forced so much apart by the staphyloma that ectropion de- 
velops. 

Staphyloma of the cornea is almost invariably accompanied by eleva- 
tion of tension. With regard to the relation between this and the 
staphyloma, two sets of cases exist — i. e., the increase of tension may be 
the cause or the result of the staphyloma. The former is the case when 
the cicatrization of the prolapsed iris has produced seclusion of the 
pupil, a condition which first causes increase of tension, and then, as a 
consequence of this, ectasis of the cicatrix. (See above the remarks on 
secondary protrusion.) The second class of cases comprises all those 
staphylomata which have originated under normal conditions of tension 
and are hence due simply to the yielding character of the scar. In 
these the increase of tension does occur as an additional symptom, but 
not till later. 

In addition to the increase of intra-ocular pressure that is percep- 
tible to the touch, elevation of tension finds its chief expression in a 
diminution of sight, which finally ends in complete blindness. Pain, 
too, is sometimes associated with the elevation of tension. Moreover, as 
soon as the increase of tension has set in, it gives rise to further changes 
both in the staphyloma and also in the whole eyeball. Thin-walled 
staphylomata are made to protrude farther and farther by the height- 
ened pressure, and thus suffer an increasing attenuation of their wall, 
until the latter, from almost any trifling cause, ruptures at some particu- 
larly yielding spot. Then the aqueous humor is discharged in great 
abundance ; and the staphyloma collapses, becomes smaller, and remains 
so for some time. But then the eyeball slowly fills again up to its former 
volume, and rupture takes place a second time. Thus the process may 
be repeated a number of times at pretty long intervals, until at length a 
time comes when perforation of the staphyloma is followed by profuse 



216 DISEASES OF THE EYE. 

intra-ocular hEemorrhage, or by severe irido-cyclitis or panophthalmitis. 
Then the eyeball undergoes atrophy, and by this means a sort of spon- 
taneous cure of the staphyloma takes place. 

The scleral portion of the eyeball, too, when the elevation of tension 
has lasted a pretty long time, gives way and becomes distended, espe- 
cially in young people in whom the sclera is more extensible. In this 
case we observe both total and partial ectasia of the sclera. In the 
former, the sclera becomes uniformly distended, the entire eyeball grows 
larger, and the sclera becomes so thin as to look bluish owing to the 
way in which the chorioidal pigment shines through it. In the second 
case, the sclera in the vicinity of the cornea bulges forward under the 
form of a circumscribed swelling, which appears dark from the pigment 
shining through it ; intercalary and ciliary staphylomata (see § 55) are 
developed. Very frequently general and partial ectasia of the sclera 
are found simultaneously in the same eye, which may thus grow to an 
enormous size. 

47. Treatment. — Stress is chiefly to be laid upon prophylaxis. The 
physician who has to treat an eye with prolapse of the iris must make 
every endeavor to secure the production of a flat cicatrix. He should 
not sufller a staphyloma to develop before his very eyes. In this con- 
nection, what has been said in regard to prolapse of the iris (page 156) 
may be consulted. When we have succeeded in effecting the formation 
of a flat cicatrix we must, while the latter is still recent, take measures 
to keep it from bulging out again. With this end in view we should 
refrain from discharging the patient too soon from treatment, and par- 
ticularly we must advise him to abstain for a long time from all severe 
physical exertion. It is often advisable before discharging the patient 
to perform an iridectomy, whenever this can be done, as by this means 
the subsequent development of an ectasis is most effectually counter- 
acted. 

If we have to do with a staphyloma which has already developed, 
our treatment must have a different object in view, according as the 
case in hand is a total or a partial staphyloma. With the former the 
sight is irreparably lost, since there is no transparent cornea left ; we 
must hence confine ourselves to the Telief of the symptoms and of the 
disfigurement produced by the staphyloma. With partial staphylomata, 
our first aim is to improve whatever sight may be left, or at least to 
preserve it from further injury (as would be produced by increasp of 
tension). The methods which are employed for the cure of staphy- 
loma are all of an operative character. 

(a) Total Staphyloma. — The simplest procedure is incision of the 
staphyloma. This is done with the expectation that as a consequence 
of it the staphyloma will collapse, and, because of the retraction of the 
cicatricial tissue of which it consists, will remain permanently flat. 
This procedure is evidently crowned with success only when the staphy- 



DISEASES OP THE CORNEA. 



217 



loma is thin- walled enough to collapse after the incision has been made ; 
it is, therefore, indicated only in those recent staphylomata which are 
still akin to prolapse of the iris. The incision is made by means of a 
cataract knife. The section is made in various ways : either in a recti- 
linear direction and transversely across the middle of the staphyloma 
(Kiichler), or in a curved direction and concentrically with the lower 
corneal margin, so that a flap is formed of the wall of the staphyloma. 
The latter way of making the section has the advantage of causing a 
marked gaping of the wound, since the flap contracts owing to the 
drawing up of the cicatricial tissue. Consequently, the lips of the wound 
are prevented from rapidly reuniting, in which case the ectasis would 
soon be reproduced and the incision would have to be repeated. If 
the wound in the flap should not gape sufficiently, the flap must be re- 
trenched by the removal of a part of it. After the completion of the 
section, the lens, in case it is still in the eye, must be removed by lacerat- 
ing the anterior capsule. 

Simple ablation of the staphyloma by Beer's method is performed 
by first separating the lower half of the staphyloma from its base by a 
curved incision made with the cataract knife. The flap thus formed is 
grasped with the forceps, and then the upper half of the staphyloma is 
cut off from its base by means of the scissors. The lens, which now pre- 
sents, is removed by opening the capsule. The gap which has been 
substituted for the staphyloma by the operation may now be left to be 
closed by the unaided action of cicatrization. It is better, however, to 
close the gap by sutures passed through the upper and lower margins of 
the staphyloma, which have been left for the purpose. These sutures 
on being drawn tight bring the lips of the wound together horizontally. 

A still more secure union is effected if we follow up the ablation with 
a conjunctival suture (De Weaker), and it is in this way that the opera- 
tion is usually performed at present. We begin the operation by divid- 
ing the conjunctiva all round the limbus and separating it for some 
little distance from the subjacent sclera, so that it can be drawn for- 
ward to the proper extent. Then we pass the threads through the free 
edge of the conjunctiva. We do this by running through the upper 
and lower edges a number of vertical threads, which subsequently are 
tied so as to form interrupted sutures. Before the sutures are drawn 
tight, we ablate the staphyloma as in Beer's method, and expel the lens 
from the eye. Then we close the conjunctival wound by knotting the 
sutures. We may also apply the suture by passing a single thread in 
and out all round the margin of the detached conjunctiva, in such a 
way that the two ends of the thread come out close by each other, and, 
when they are knotted together, constrict the conjunctiva after the 
manner of a tobacco bag (tobacco-bag suture). In this case, too, the 
ablation of the staphyloma and the delivery of the lens are not done 
until after the thread has been passed through the conjunctiva. For, 



218 DISEASES OP THE EYE. - 

after the removal of the lens, there is imminent danger of the expulsion 
of the vitreous, and hence we ought not to be losing time in applying 
sutures, but, on the contrary, should have it in our power to close the 
wound promptly by tying a thread that has been already passed. 

Ablation with the application of a suture is suitable for all cases of 
old staphylomata with thick walls, for which incision alone would not 
be sufficient. 

Those cases of staphyloma of the cornea in which a considerable 
ectasis of the sclera has developed as the result of an increase of ten- 
sion are in general not adapted for ablation. We should then run the 
risk of getting a violent hsemorrhage in consequence of the sudden 
diminution of the previously increased tension. For such cases, in 
which the eyeball is increased sometimes to quite an enormous size, 
the only thing feasible is enucleation, which relieves the troublesome 
symptoms and at the same time also the disfigurement, inasmuch as 
an artificial eye can then be Worn in place of the hideous, enlarged eye- 
ball. For the method of performing enucleation, see the section on 
Operations (§ 165). 

ip) Partial Staphyloma. — In this, treatment seeks a threefold ob- 
ject : to improve the sight, to cause flattening of the ectasis, and to 
prevent the development of an increase of .tension, or to do away with 
it in case it has already set in. 

Simple ificision, which must be followed up by the application of a 
pressure bandage for a pretty long time, accomplishes its end only in 
recent staphylomata, the walls of which are still thin. In older and 
thicker cicatrices, excision, with or without the operation of uniting 
the edges of the wound by sutures, is to be preferred. But the most 
approved remedy that we possess against ectatic cicatrices is iridec- 
tomy. This should be performed in such a way that the incision lies 
in the sclera and a broad coloboma is produced, reaching to the margin 
of the iris. We do not select for iridectomy that part of the iris which 
is drawn into the cicatrix, as we might do with the idea of relieving in 
this way the incarceration of the iris ; an iridectomy at this spot would 
on technical grounds be very difficult of performance, and often would 
turn out to be imperfect. We try rather to find for our iridectomy 
that spot which represents the greatest improvement that can be made 
in the vision, the pupil being shifted to a point behind the most trans- 
parent part of the cornea. Furthermore, by means of the iridectomy, 
an increase in tension is prevented from developing, or, if it has al- 
ready developed, it is done away with. Moreover, in cases of staphylo- 
mata with thin walls, a flattening of the ectasis is obtained by the iri- 
dectomy, if the eye is kept beneath a pressure bandage for a long time 
after the operation. In thick- walled and unyielding staphylomata, it 
is advisable to combine excision with iridectomy. We begin by doing 
the former, and put off the iridectomy to some weeks later, when the 



DISEASES OF THE CORNEA. 219 

formation of a flat cicatrix has taken place — doing this in order to pre- 
■vent the renewed bulging of the freshly formed cicatrix. 

If we have to do with a partial staphyloma in which, owing to the 
increase in tension, the sight has been already either in great part or 
altogether annihilated, no gain in this regard can be expected. Never- 
theless, it will be advisable to perform an iridectomy in most cases in 
order to prevent the further consequences of the increased tension, 
such as partial ectasis of the sclera., enlargement of the entire eyeball, 
etc. Of course, iridectomy can be performed in such cases only so long 
as the anterior chamber is still existent. As soon as the iris, in conse- 
quence of the increased tension, has been squeezed against the posterior 
surface of the cornea and has become cemented to it, the performance 
of iridectomy has become technically impossible. 

It can not be denied that, in spite of the therapeutic means at our 
command, the cicatrix in many eases keeps constantly bulging anew, 
the increase in tension returns every time, and thus the eye slowly but 
inevitably goes blind. 

Anatomy of Staphyloma op the Coenba. — The wall of the staphyloma 
consists of a dense, tough cicatricial tissue, which is traversed by a few vessels, 
and often contains pigment imbedded in it. The thickness of the wall differs 
greatly; it varies from the thickness of a sheet of paper to a thickness three 
times as great as that of the normal cornea, and more. Very thick staphylo- 
mata are often as hard as cartilage, and when ablation is performed can scarcely 
be cut through. Thick and thin spots frequently occur in the wall of the same 
staphyloma (Figs. 59 and 62). The anterior surface of the staphyloma is cov- 
ered by a thick, irregular layer of epithelium, sometimes containing epithelial 
pearls. The posterior surface is frequently uneven, on account of the inequal- 
ity in thickness of the wall. It is covered by a coating of black pigment (Fig. 
59, i, and Fig. 63), which is nothing but the retinal pigment layer of the iris. 
As, however, this has to be distributed over such a large surface, it is rarefied, 
so that the epithelial coating shows numerous gaps, and in the center of the 
staphyloma, corresponding to what was once tlie pupil, it is often entirely want- 
ing. Through staphylomata with thin walls light can be passed by means of 
focal illumination, and in this way the pigment layer may be demonstrated in 
the living eye. It is easy to see why Bowman's membrane should be wanting 
on the anterior surface of the staphyloma, and Descemet's membrane on its pos- 
terior surface, since the staphyloma is not cicatrized cornea, but is iris, and rep- 
resents a spot at which the cornea has been destroyed. It is only on the sloping 
sides and the edges of the staphyloma, which are formed of the remains of the 
cornea, that both these membranes can still be demonstrated. This is more the 
case in a conical than in a spherical staphyloma. A spherical staphyloma, in 
fact, is produced in cases where the sides of the perforation shelve ofi abruptly, 
so that the cornea even in the immediate vicinity of the opening has its normal 
thickness. In this case, when the prolapsed iris is driven out into this opening, 
the adjoining corneal tissue takes little or no part in it. The sides of the pro- 
lapse rise at right angles to the adjoining corneal surface, and thus a spherical 
staphyloma is formed (Fig. 59). A conical staphyloma, on the other hand, is 
the result of a less extensive perforation (Fig. 60), in which the portions of cor- 



220 DISEASES OF THE EYE. 

nea forming the walls of the aperture taper down toward the latter, and on ac- 
count of their thinness are driven forward at the same time with the prolapsed 
iris. The fully developed ectasis, therefore, consists only in its central part of 
old prolapsed iris, its lateral slopes being in large part formed of the tapering, 
protruded cornea (Fig. 63). For this reason the ectasis does not rise abruptly 
from the cornea, but presents a gradual slope from its margin up, so that a 
conical shape is thus given to it. 

In staphyloma the iris persists as an independent structure only in cases in 
which at least a part of the pupil has remained free, so that the anterior and 
posterior chambers can communicate through it. If, on the other hand, the 
entire pupillary border has been incorporated in the cicatrix (seclusio pupillse), 
increase of tension sets in, and as the iris is consequently pushed forward right 
up to the cornea (Fig. 61), the shallow anterior chamber, which was present at 
the outset (Figs. 58 and 60, «), disappears. Then the iris becomes more and 
more intimately adherent to the cornea, and becomes constantly thinner and 
thinner as a result of atrophy, so that at last scarcely anything of it but the pig- 
ment layer remains to cover the posterior surface of the staphyloma (Fig. 62). 
In such cases, even when the marginal portions of the cornea are still somewhat 
transparent, the performance of an iridectomy has become technically impos- 
sible. 

As the anterior chamber becomes shallower the posterior becomes deeper; 
in total staphylomata, the whole large space between the posterior surface of 
the staphyloma and the lens is to be looked upon as the posterior chamber 
(Figs. 59 and 62). 

The ciliary body suffers mainly on account of the increase in tension, which 
causes it to atrophy, especially if an ectasis of the sclera develops in the ciliary 
region (staphyloma ciliare). Furthermore, the ciliary processes are sometimes 
very strongly pulled upon by the fibers of the zonula, and are thus elon- 
gated (c, Fig. 59). 

The lens very frequently suffers changes in the case of staphylomata. In 
total staphylomata it is often entirely wanting, because it has been discharged 
from the eye through the pupil at the time when a large perforation existed. 
If the lens is still present it frequently shows alterations of position, being 
tilted in consequence of the unequal bulging of the staphyloma. Sometimes 
we find it partially adherent to the staphyloma, or it vibrates with the move- 
ments of the eye, because of the atrophy of the stretched zonula of Zinn. These 
alterations in the lens favor the development of an increase in tension; for this 
reason, after performing incision or ablation of the staphyloma, we remove the 
lens from the eye. Very frequently the lens is rendered opaque either in toto 
or only at its anterior pole (anterior polar cataract, p, Fig. 59). In some few 
cases we may find the lens greatly diminished in size, or even shrunken into a 
mere membrane (Fig. 62). 

The deeper parts of the eye also suffer from the increase in tension. Exca- 
vation of the optic nerve, atrophy of the retina and chorioid, and fluidity of the 
vitreous may develop. 

As a rule, the increase of tension resulting from staphyloma develops quite 
gradually. But sometimes protrusion of the cicatrix and increase of tension 
take place simultaneously and in a sudden fashion, as the following example 
may illustrate: A person has had an ulcus serpens which has destroyed the 
cornea in its central part. Under suitable treatment the prolapsed iris is in 



DISEASES OF THE CORNEA. 



221 



process of transformation into a flat cicatrix. Then, one morning the patient 
complains of violent pain which has suddenly developed in the eye. After re- 
moving the bandage we find the eye, which the day before was almost free 




Fig. 60. 




Fig. 61. 



Fig. 62. 



Figs. 60-62.— Development op a Total Conical Staphyloma. Magnified 3x1. 

Fig. go. — A large ulcer has destroyed the central portions of the cornea. Into the aperture left 
by the jaerforation projects the iris ; on the right side, r, presenting only its pupillary bor- 
der, while on the left side, I, it forms a real prolapse. A gray mass, e, composed of coagu- 
lated fibrin, pus corpuscles, and det-ritus, fills the perforation and covers the exposed iris. 
The anterior chamber, v, is very shallow, and nevertheless the posterior chamber has be- 
come shallower as well, because the lens is pushed forward. Moreover, the latter, owing 
to the relaxation of the zonula, has an increased curvature. 

Fig. 61.— In place of the prolapsed iris a somewhat protuberant scar has developed, which is 
thinner than the cornea, and in which is included the entire pupillary margin of the iris. In 
consequence of this seclusio pupillse the whole iris has been pushed forward right up against 
the cornea, so that the anterior chamber has disappeared and the posterior chamber has 
become correspondingly deeper. The lens has re-acquired its normal shape, and shows 
beginning opacification of its cortical layers and wrinkling of the anterior capsule in the 
region formerly occupied by the pupil, k. 

Fig. 63.— The increase of tension that has set in as a result of the seclusio pupilla3 has produced 
a uniform protrusion of the marginal portions of the cornea, which now form the sloping 
sides of the conical protuberance, and which are not separated by any sharp line of de- 
marcation from the central cicatrix. On the right side of the drawing the iris can still be 
made out, although fast adherent to the cornea and greatly atrophied. On the left side 
nothing is left of the iris but the retinal pigment layer coating the posterior wall of the 
staphyloma. The wall of the staphyloma shows various protuberances caused by the con- 
stant increase in tension. The largest of these, a, situated directly in front of the ciliary 
body, represents a beginning intercalary staphyloma. The posterior chamber is very deep, 
the ciliary body, owing to atrophy, is flattened out, and the lens is shrunken, flat like a cake^ 
and presents a capsular thickening, k. 

from irritation, now the seat of a dusky ciliary injection. The cicatrix is bulged 
forward in the form of a cone, and the anterior chamber is very shallow, or is 
altogether abolished, because the iris is pressed against the cornea. The latter 
looks dull, and small hemorrhages are visible in the cicatrix or in the anterioi 
chamber. The eye is hard, and very sensitive to the touch. An external cause 
for this sudden change in the course of healing is generally not discoverable. - 

The operation for total staphyloma is performed most frequently by making 
an ablation with consecutive suture of the conjunctiva. In this case it very 
often happens that some days after the operation the conjunctival suture gives 
way, and the gap left by the removal of the staphyloma comes to view with 
vitreous hanging out from it. Since this gap closes but very slowly by cica- 
trization, the process of healing is very much protracted, and, furthermore, pan- 



222 DISEASES OP THE EYE. 

ophthalmitis may result from purulent infection of the projecting vitreous. To 
prevent this, and to obtain the securest possible closure of the wound, we may 
proceed as follows: After making the circular incision in the conjunctiva, but 
before removing the staphyloma, we carefully scrape away the limbus and also 
the epithelium at the edge of the staphyloma, since, otherwise, if these sur- 
faces are left covered with epithelium, the conjunctiva that is sewed over 
them will not adhere to them. Then we remove the staphyloma, leaving above 
and below a narrow rim of margin through which are passed the sutures that 
close in the gap in the eyeball; and last of all the conjunctiva is drawn over 
the wound and united. 

In small, partial staphylomata, which so often defy-all attempts at cure, I 
have got favorable results bj t/ransplantation of the cornea. I remove the ectatic 
cicatrix with the trephine, and then carefully excise the iris at the edges of the 
opening, so that it no longer remains connected with the cornea. Then I place 
in the gap an equally large piece of cornea taken from a just enucleated human 
eye. Generally this piece becomes well incorporated, and even if after incor- 
poration it subsequently becomes opaque, the object that it was intended to 
subserve is nevertheless obtained, in that the staphyloma is replaced by a flat 
cicatrix not adherent to the iris. 



2. Keratectasia. 

48. By keratectasia we understand a protrusion of the cornea, which 
makes its appearance after inflammation of the latter, without, how- 
ever, any perforation having taken place. The protrusion, therefore, 
in this case consists of corneal tissue, in contradistinction to staphylo- 
mata, in which it is formed of the tissue of the iris. From ectasise of 
the cornea of non-inflammatory origin — i. e., keratoconus and kerato- 
globus — the inflammatory ectasia of the cornea is distinguished by the 
fact that the bulging portion of the cornea, in consequence of the in- 
flammation, is opaque. 

Inflammation produces protrusion of the cornea by thinning it or 
by softening it. It produces protrusion by thinning in those cases in 
which an ulcer of the cornea has destroyed the superficial Ikmellis of 
t^e latter to such an extent that the posterior lamellae are no longer able 
by themselves to offer resistance to the intra-ocular pressure (keratectasia 
ex ulcere, Fig. 63). If all the layers as far as the membrane of Des- 
cemet have been destroyed, a hernia of this membrane (keratocele) is 
produced, which may cicatrize in this ectatic form. In this case this 
hernia persists as a perfectly transparent vesicle which projects above 
the surface of the cornea, and which is surrounded by an opaque cica- 
tricial ring. 

Ectasis of the cornea may also take place because of a softening 
that results from inflammation. Under this head belong the keratec- 
tasia e panno, which develops when a thick pannus penetrates pretty 
deeply into the cornea proper, and the keratectasia following paren- 
chymatous keratitis. In these cases the cornea protrudes as a whole 



DISEASES OF THE COENEA. 



223 



and uniformly, while in keratectasia ex ulcere it is generally only a 
local protrusion that exists. 

A consequence common to all inflammatory ectasias of the cornea is 
that the protruding portions have very little power of regaining their 
transparency. Accordingly, the prognosis for vision in pannus, kera- 
titis parenchymatosa, etc., must be regarded as essentially more un- 




-<Z 



Keratectasia ex Ulcere. Magnified 25 x 1. 



The thinned and bulging cicatrix, N, is distinguished from the surrounding normal cornea by 
Its denser structure. The epithelium, c, over it is thickened, while Bowman's membrane, b, 
is wanting in this spot. On the other hand, Descemet's membrane, d, along with Its epithe- 
lium, is everywhere present — a proof that the ulcer has not perforated. 

favorable as soon as protrusion of the cornea shows itself. And in 
considering the prognosis we must take into account, besides the opac- 
ity of the bulging cornea, its alteration in curvature and the resulting 
alteration of refraction of the eye. Sometimes keratectasia is followed 
by increase of tension. 

Treatment is powerless against a fully developed keratectasia ; it is 
attended with success only when there is a question of combating a 
protrusion that is in process of development. The means suited for 
this latter purpose are repeated punctures of the cornea with the sub- 
sequent application of a pressure bandage, and iridectomy. Very small 
ectasiae, as, for example, small keratoceles, we may perforate with a 
cautery point and then induce the formation of a flat cicatrix by the 
long-continued application of a pressure bandage. 



S. Keratoconus. 

49. Symptoms and Course. — In keratoconus, the central part of the 
cornea very gradually and without inflammatory symptoms begins to 
bulge forward in the form of a cone. At first the cornea is perfectly 
transparent, and its peripheral portions keep their normal curvature. 
Accordingly, the bulging forward of the center of the cornea, as long as 
it has not advanced too far, is recognized only by the diminution in 
size which the corneal reflex presents in the central part of the cor- 
nea. In the subsequent course of the disease the bulging of the center 
consta,ntly increases, and the peripheral parts of the cornea are also in- 



224 DISEASES OP THE EYE. 

volved in the conical projection, so that we can perceive the conical 
shape of the cornea at a glance, especially when we look at the eye 
from the side. Finally, the apex of the cone becomes opaque and its 
surface uneven. 

To the patient the disease makes itself apparent only by the dis- 
turbance of vision. The eye becomes apparently myopic, so that all 
objects have to be brought up very close. Nevertheless, perfectly sharp 
vision is not attainable by means of spherical concave glasses, because 
the bulging of the cornea is not spherical, but conical (hyperbolic). 
By the development of the opacity at the apex of the cone the visual 
power is, of course, still further reduced. 

Keratoconus is a rare disease, which, as a rule, affects both eyes. It 
begins for the most part between the twelfth and the twentieth year, 
develops very gradually in the course of years to the height above de- 
scribed, and ultimately, sooner or later, comes to a standstill. A sub- 
sidence of the ectasis is not observed ; but ulceration or rupture of the 
cornea is not observed either. Nor does increase in tension, which so 
frequently develops in inflammatory ectasia of the cornea, occur. 

The cause of the protrusion lies in a progressive thinning of the 
central portion of the cornea, which consequently gives way before the 
intra-ocular pressure. By what means this thinning is produced is un- 
known. 

Treatment can point to but slight results in this disease.. In recent 
cases that have not yet gone too far, we may try to put a stop to the 
process by thorough protection of the eye, by general corroborative 
measures, and by the long-continued instillation of a miotic (eserine or 
pilocarpine). The marked contraction of the pupil thus produced 
lowers the tension in the anterior chamber, and thus lessens the strain 
imposed upon the attenuated cornea. A few cases have been thus put 
a stop to (Arlt). Finally, a series of methods aims at the substitution 
of a resistant cicatrix for the attenuated apex of the cone. For this 
purpose the latter is destroyed by excision or by cauterization. Since 
the corneal cicatrix thus obtained lies directly in front of the pupil, a 
displacement of the pupil to one side by means of an iridectomy is 
afterward usually required. 

4- Keratoglolus. 

50. In keratoglobus, the cornea as a whole is larger than normal. 
Keratoglobus is but one of the symptoms of the general enlargement 
of the eyeball that constitutes hydrophthalmus (buphthalmus), and 
for this reason reference must be made to the latter disease (§ 83) for 
its description. 

By many authors the expression staphyloma corneee is employed in a broader 
sense, and all ectasia of the cornea are designated under this name. In that 



DISEASES OP THE CORNEA. 225 

case a further division of the term is made by distinguishing the transparent 
ectasiee of the cornea, keratoconus and keratoglobus, under the name of staphy- 
loma pellucidum, from cicatricial staphylomata and from keratectasiae. 

In heratoconus, the tliinning of the cornea within the area of the conical pro- 
trusion can be demonstrated by the ease with which the apex of the cone 
can be dimpled by means of a sound. Anatomical examinations also have 
demonstrated that the cornea may be reduced in its center to a third of its 
normal thickness (Wagner, Hulke). A keratoconus of slight degree may be 
readily overlooked, since the cornea is perfectly transparent. The diagnosis, 
however, can be made even in the earlier stages by examining the corneal re- 
flex, particularly if we use Placido's keratosoope (§ 148) for the purpose. 
Again, if we illuminate the pupil with the ophthalmoscope, we see in the red 
field of the former an annular shadow which is particularly dark at one spot ; 
this spot shifts with the movements of the mirror. 

In high degrees of keratoconus, in which the apex is already opaque, the 
distinction from a keratectasia following a central ulcer of the cornea is often 
very difficult. We must then take into consideration the condition of the other 
eye. In keratoconus we almost always find the second eye diseased as well, 
although not ordinarily to the same extent; while a central keratectasia could 
only by a rare accident be present at the same time in both eyes. 

Keratoconus affects the female more frequently than the male sex. Those 
attacked by it not only see worse in the line of direct vision, but their indirect 
vision is also impaired, since the rays which enter the eye through the sides of 
the cone are very irregularly refracted. The consequence of this is faulty 
orientation in going about, such as is not present in simple myopia even of 
very high degree (Arlt). A moderate improvement of vision can generally be 
obtained by the use of strong concave spherical glasses, either alone or com- 
bined with concave cylinders. In many cases the hyperbolic glasses proposed 
by Raehlmann do good service. With these, the patient, to see clearly, must 
look just in line with the optical axis of the glass ; they can not, therefore, be 
used for sidelong vision, and consequently not for going about. The same is 
true of the stenopseic aperture, which, held in the patient's hand close before 
his eye, facilitates the recognition of small objects, such as fine print. 



Tumors of the Cornea. —Tumors that develop primarily in the cornea 
are among the greatest of rarities. Isolated mstances of primary papilloma, 
fibroma, myxoma, and sarcoma of the cornea have been published. The car- 
cinomata and sarcomata which not infrequently are observed upon the cornea 
do not originate there, but in the adjacent conjunctiva, and in fact generally in 
the limbus. These tumors have been already considered under the head of 
diseases of the conjunctiva ; so also has been the dermoid, a congenital form of 
tumor, situated partly upon the cornea, partly in the conjunctiva. 



15 



CHAPTER III. 
DISEASES OF THE SCLERA. 

Anatomy. 

51. The sclera,* together with the cornea, forms the fibrous enve- 
lope of the eye, the shape of which is nearly that of a sphere having 
a constriction corresponding to the base of the cornea. The mean 
diameter of this sphere (length of the axis of the eye) amounts to 
twenty-four millimetres. The sclera is thickest in the posterior seg- 
ment of the eyeball, where it has a thickness of about one millimetre. 
It gradually diminishes in thickness anteriorly, becoming, however, 
somewhat thicker in the most anterior segment, because here the ten- 
dons of the recti muscles become fused with and reinforce it. 

The histological structure of the sclera is very similar to that of the 
cornea. The sclera consists of fine fibrillte of connective tissue, which 
are united into bundles. These run, generally speaking, in two direc- 
tions — from before backward (meridional fibers), and in a direction 
concentric with the margin of the cornea (circular or equatorial fibers). 
Between the bundles are found lymph spaces which are in part lined 
with flat cells, thus forming an analogy with the system of lymph 
gfiaces and the corneal corpuscles of the cornea. The tissue of the 
sclera and of the cornea are hence very similar to each other, and, 
moreover, at the corneal margin pass into each other without any 
sharp line of demarcation. They are chiefly distinguished by the ar- 
rangement of the bundles of fibers, which is much more regular in the 
cornea than in the sclera. 

The sclera also contains branched pigment cells, which for the most 
part are met with only in its deep layers and also along the vessels and 
nerves that traverse it. In the living eye we often perceive the pig- 
ment in the spots where the anterior ciliary veins emerge from the 
sclera, these spots appearing as small brown dots upon the white mem- 
brane. Sometimes we find in the human eye larger, slate-colored or 
light violet spots upon the sclera d.ue to an abnormal pigmentation. 
Such pigmentation as this is the rule in many animals. If the sclera 
is thin, the pigment of the subjacent chorioid is seen as a dark sub- 
stance shining through it. In this case, which occurs especially in chil- 
dren, the white of the eye has a bluish tint, like thin white porcelain. 

* From <TK\r\p6s, hard. 
236 



DISEASES OF THE SCLERA. 



227 



The sclera is traversed by vessels and nerves which penetrate into 
the interior of the eye, but has itself very few vessels. On the other 
hand, there are numerous vessels contained in the so-called episcleral 
tissue, that loose connective tissue which envelops the sclera and in the 
anterior segment of the eye attaches the conjunctiva to it. In the 
posterior segment of the eye the optic nerve passes through the sclera, 
which here apparently has an aperture for the passage of the nerve 
(foramen sclerse). In reality, however, the inner layers of the sclera 
are continued as the lamina cribrosa through the foramen scleras (Fig. 
9 ; for more precise particulars, see § 100). 



I. Inflammation of the Sclera. 

52. Inflammation of the sclera (scleritis), which belongs among the 
rarer affections of the eye, is always limited to the anterior segment 
of the sclera, lying between the equator of the eyeball and the margin 
of the cornea. It sometimes affects only the superficial layers of the 
sclera, sometimes the deep layers also. In the first case the disease 
runs its course without entailing any injury upon the eye; but in the 
second case it is dangerous to the sight, inasmuch as the inflammation 
passes from the sclera to the other membranes of the eye. It is hence 
of practical importance to distinguish between a superficial and a deep 
form of the disease (episcleritis and scleritis of authors). 

(a) Superficial Form of Scleritis {Ejnscleritis). 

This form makes its apjoearance as a focal inflammation, a circum- 
scribed inflammatory nodule forming in the sclera. At the affected 
spot the sclera, owing to the deposition of exudate, bulges out in the 
form of a boss, so that a prominence which is sometimes flat, sometimes 
more acute, and which may reach or surpass the size of a lentil, is found 
here. This is traversed by vessels which, because deeply situated (epi- 
scleral), are violet in color ; and it is immovably attached to the sclera, 
while the conjunctiva, though to be sure injected, can be moved about 
freely. The nodule feels hard, and is sometimes very sensitive to the 
touch. Except at the site of the nodule the eye may be perfectly free 
from injection. The subjective disturbances vary greatly ; frequently 
the disease is associated with but slight discomfort for the patient, while 
in other cases very violent pain is present, which for a long time de- 
prives the patient of sleep. 

In the subsequent course of the disease disintegration and ulcera- 
tion of the nodules never occur ; on the contrary, they always disap- 
pear by resorption. After the inflammation has remained at its acme 
for some weeks, the nodule gradually flattens, becomes paler, and at 
length disappears completely, after lasting altogether from four to eight 



228 DISEASES OP THE EYE. 

weeks. Sometimes it leaves no trace behind it; more frequently, how- 
ever, at the spot where it was situated a slate-colored patch is left, and 
in the same place the sclera appears somewhat depressed and the con- 
junctiva is closely adherent to it (cicatrix in the sclera). In other 
respects the eye suffers no after-injury from the inflammation. 

Scleritis is peculiarly proue to recur. The disease may, to be sure, 
stop with one or two attacks, or years may intervene between the at- 
tacks ; but in other cases, scarcely has the first nodule disappeared — 
nay, even the first one may not have disappeared — when a second one 
appears upon another portion of the sclera. Sometimes the disease 
does not cease until nodules have developed, one after another, in the 
entire circuracorneal space, and at length a zone of gray discoloration 
is visible entirely surrounding the cornea. By this time the disease 
has exhausted itself, since a new nodule does not generally develop in 
the spot where another was situated before. But, before it has gone 
as far as this, several years may have elapsed, during which the patient 
with but brief interruptions is annoyed by attacks of inflammation. 
In addition to this the disease very frequently attacks both eyes. The 
prognosis of the superficial form of scleritis is hence unfavorable in 
respect to the duration of the disease ; while with regard to the final 
outcome it must be stated as favorable, because the usefulness of the 
eye for vision suffers no impairment, even if the process lasts a long 
time. 

Superficial scleritis occurs, as a rule, only in adults, and especially 
in elderly people. In some cases it appears to be connected with rheu- 
matic or gouty affections ; in others its origin is obscure. Treatment 
avails but little against it. We are able to ameliorate the symptoms 
and accelerate somewhat the subsidence of the nodules, without having 
it in our power to prevent the recurrences. Sodium salicylate is given 
internally, if there are any grounds for the assumption of a rheumatic 
origin for the disease ; otherwise, diaphoretic methods of treatment, 
derivative remedies in the shape of mildly purgative mineral waters, 
iodide of potassium, etc., may be recommended. As regards local 
remedies, we may try to produce more rapid subsidence by means of 
massage (Pagenstecher). Pat, either without addition or under the 
form of the yellow-precipitate ointment, is introduced into the conjunc- 
tival sac, and the nodule, which can be felt through the lid, is then 
rubbed and squeezed through the lid by means of the fingers. If the 
disease is associated with violent pain, we may employ moist and warm 
compresses, atropine, and local blood-letting (six to ten leeches upon 
the temple) in addition to the massage : the latter procedure, indeed, 
in these cases frequently can not be performed because the nodule is 
too painful. In this event the application of the constant current to 
the nodule by means of a small electrode (Keuss) or the scarification 
of the nodule (Adamiick) has been recommended. 



DISEASES OP THE SCLERA. 229 

(b) Deep Forms of Scleritis. 

In this form, too, a swelling of the sclera exists, which may make 
its appearance under the form of isolated prominences, but which more 
frequently is not so sharply circumscribed. In the latter case the 
sclera shows an extensive bluish-red injection, sometimes covering the 
whole circumcorneal region, and a more uniform swelling not com- 
posed of isolated prominences. Later the sclera in this situation often 
takes on a peculiar pale-violet color and a transparent look, that make 
it resemble fine porcelain. But the deep is distiDguished from the 
superficial form most of all by the course of the infiammation and by 
its being communicated to other parts of the eye. 

The inflammation in the sclera in this case as in the superficial form 
leads not to disintegration of the inflammatory products, but to their 
disappearance by resorption with the formation of a residual dark-col- 
ored cicatrix. In the meantime, however, the sclera has been undergo- 
ing considerable attenuation at the site of the cicatrix, so that it is no 
longer able to offer resistance to the intra-ocular pressure, even though 
this does not exceed its normal amount. Hence ectasis of the diseased 
spot occurs. This makes its appearance under two forms — either as 
simple enlargement of the surface, or as a gibbous protrusion of the 
thinned-out portions of the sclera. In the former case the entire cir- 
cumcorneal zone of the sclera, which has been colored gray by the 
scleritis, becomes constantly more and more dilated. Consequently, 
the cornea, together with the adjacent portions of the sclera, is pro- 
jected forward, so that the eyeball is elongated in a sagittal direction 
and becomes pear-shaped. In the second case, on the contrary, a cir- 
cumscribed protrusion of the thinned-out spots, raising them above the 
level of the healthy sclera, is produced, so that there are seen rising 
about the cornea a number of humps, which, because of their thin walls, 
show the dark pigment shining through. As these are comprised in 
the region of the ciliary body, they are called ciliary staphylomata (see 
page 348). 

Complications affecting other portions of the eye are likewise a 
peculiarity of the deep form of scleritis. They affect both cornea and 
uvea. In the cornea, infiltrates, deeply situated, develop, which do not 
break down into pus but become absorbed again, leaving a permanent 
opacity (sclerosing keratitis, see page 195). In the iris we find the 
signs of iritis, mainly under the guise of posterior synechias and even 
of occlusio pupillae, but never of hypopyon. In the chorioid, the in- 
flammation affects chiefly its most anterior portion, and causes injury 
to vision chiefly through the accompanying opacities in the vitreous. 
So in this form of scleritis almost all parts of the eye suffer ; and for 
this reason it must be looked upon as much more dangerous than the 
superficial form. 



230 DISEASES OP THE BYE. 

Deep scleritis almost always affects both eyes, and, as treatment is 
unable to arrest it, is prolonged over a course of years. It leads to the 
formation of dense corneal opacities, to seclusio pupiilee with its baneful 
consequences, to opacities of the lens and vitreous, to myopia of high 
degree due to the elongation of the axis of the eye, and finally to eleva- 
tion of tension due to the ectasise in the sclera. Hence the disease al- 
ways ends by producing great impairment or even complete loss of 
sight. 

The deep form, in opposition to the superficial variety, mainly 
affects young people (but not children). It is often found in conjunc- 
tion with the signs of scrofula, tuberculosis, or hereditary syphilis. In 
the female sex, which is more frequently attacked than the male by 
this disease, disturbances of menstruation appear to furnish the excit- 
ing cause. 

Treatment has very little power over deep scleritis. It has first of 
all to combat by dietetic and medicinal remedies any constitutional af- 
fection that may lie at the root of the disease, and for this purpose the 
preparations of iodine (iodide of potassium, iodide of iron, iodureted 
mineral waters), or, in case of the disturbances of menstruation, the 
preparations of iron are employed. As concerns the eye itself, the in- 
flammation of the cornea and iris mast be treated in the appropriate 
way. In the subsequent course of the disease iridectomy is frequently 
required, either for optical reasons, to place the pupil behind that part 
of the cornea that is still transparent, or to prevent the elevation of 
tension which may be excited by the seclusio pupillse or by the ectasiee 
of the sclera. Iridectomy, however, should, if possible, not be per- 
formed until after the subsidence of all inflammatory symptoms. 

The superficial and the deep variety of scleritis are not at all shai-ply dis- 
tinguished from each other, but show many transition forms. We can not, in 
fact, see in the living eye how far the inflammation penetrates into the sclera. 
When we make the assumption that in the deep form the inflammation does 
extend more deeply, we have no direct proof of it ; we can only infer this in- 
directly from the subsequent thinning of the sclera and from the spread of the 
inflammation to the subjacent uvea. In fact, many authors assume that the 
real starting point of the inflammation in this form lies in the uvea, and they 
call it, therefore, sclero-chorioiditis or uveo-scleritis. 

In one case of deep scleritis that Dr. Kostenitsch examined in my clinic, 
the nodule externally visible corresponded to a very dense infiltration with 
round cells which mainly occupied the middle layers of the sclera (Fig. 64). 
From these foci the infiltration extended both forward into the cornea (scleros- 
ing keratitis) and backward into the ciliary body and the iris. 

Scleritis in the well-marked cases is a very characteristic and easily recog- 
nizable disease. In light and abortive cases the diagnosis is sometimes diffi- 
cult. For instance, a scleritic nodule which is small and situated particularly 
close to the margin of the cornea, might be taken for an efliorescence of con- 
junctivitis eczematosa. The following characters may be regarded as distinc- 



231 



DISEASES OF THE SCLERA. 
t 
tive : The scleritic nodule never actually lies in the limbus, and besides is not 
situated in the conjunctiva, but beneath it, so that the latter can be moved 
about over it. Lastly, the subsequent course will soon clear up the diagnosis, 
as the eczematous nodule is converted by superficial disintegration into a con- 
junctival ulcer — a thing which never occurs with a scleritic nodule. 

In parenchymatous keratitis we sometimes find a coincident, slight but 
widely diffused, circumcorneal scleritis. Isolated nodules are sometimes also 







FiQ. 64.— Deep Sclekitis. Section through the Eebion op the Ciliary Body, taken trom 
THE Eyeball of a Twenty-fouk-year-old Girl. Magnified 24 x 1. 

The conjunctiva, B, which in the enucleation had been cut off close to the limbus, is pretty 
strongly infiltrated. In the subjacent sclera, S, are numerous narrow files of round cells, 
which show a special disposition to accompany the blood-vessels; also a large, irregularly 
shaped mass of infiltration, occupying almost the entire thickness of the sclera. The pos- 
terior section of this mass is the part that presents the most marked accumulation of cells ; 
in the anterior section the cells are most densely placed near the margin that is directed 
toward the cornea— looking as if the infiltrate were making an attempt to push its way into 
the latter. The anterior layers of the cornea, H, are occupied by quite a large infiltrate, i 
(sclerosing keratitis). In its po.sterior layers can be made out files of cells, which accompany 
the deep-seated, new-formed vessels, and which show a tendency to pass up from the deep 
to the middle layers of the cornea. The ciliary body, C, and the iris, /, are atrophic. In the 
former the ciliary processes in particular are greatly diminished in size. At the anterior 
border of the ciliary muscle can be seen the cross section, c. of the circulus arteriosus iridis 
major. The iris also is thinned, and chiefly at its peripheral portion, which over the space, 
a b, is closely appUed to the posterior surface of the cornea, and has become adherent to it. 
Descemet's membrane, d, and the lumen of Schlemm's canal are consequently no longer to 
be made out in this situation. This perijjheral adhesion of the iris is in consonance with the 
increase of tension that existed in the living eye. 



observed in the sclera as a result of syphilis, but a typical recurrent scleritis 
does not ordinarily arise from this cause. 

In many cases of diffuse deep scleritis there develop in the inflamed zone 
hard whitish nodules of the size of a pin's head, which lie beneath the con- 



232 DISEASES OP THE EYE. 

junctiva, and all at pretty much the same distauce from the margin of the cor- 
nea. They might be taken for tuberculous nodules, which, however, they are 
not. In fact, they disappear again without undergoing disintegration. 

Under the name of episcleritis periodica fugax (subconjunctivitis of Von 
Graefe) is denoted an inflammation of the vascular episcleral tissue, distin- 
guished by its transient character and by its tendency to recur. The recur- 
rences often take place with a considerable regularity at intervals of some weeks 
or months, and may keep on being repeated for years. The separate attacks 
affect sometimes one, sometimes both eyes. The eye attacked shows marked 
redness and oedematous swelling of the episcleral tissue and of the underlying 
conjunctiva. Often the inflammation is partial, in the sense that it is confined 
to one portion of the anterior segment of the eyeball, or begins in one quad- 
rant of it and travels from this to another. In severe cases contraction of the 
pupil and spasm of the ciliary muscle (temporary myopia) are present. Ordi- 
narily the inflammation runs its course and the eye becomes normal again in a 
few days. The disease is, therefore, free from danger, but owing to its fre- 
quent recurrences is very troublesome. On the whole, it is a rare affection, and 
commonly attacks persons in middle life, sometimes without known cause, 
sometimes as the result of a rheumatic or gouty tendency. Quinine, sodium 
salicylate, and treatment directed against a uratic diathesis have proved advan- 
tageous ; but many cases defy all treatment. ■ 

II. Injuries of the Sclera. 

53. Perforating Wounds of the Eyeball. — The same varieties of 
traumatism that we have observed to occur in the cornea and conjunc- 
tiva are also met with in the sclera. The first question that we have 
to ask in considering any such injury is, whether a perforation of the 
tunics of the eyeball has or has not been produced by it. Every per- 
forating injury is to be regarded as intrinsically serious, because, given 
a perforation, there is a possibility of a coincident infection of the in- 
terior of the eye ; but this almost always leads to a severe form of in- 
flammation that is very destructive to the eye. This is true for perfo- 
rating wounds of the cornea as well as of the sclera, for which reason the 
statements made in the following pages may be applied to both. 

The most important symptoms of the presence of a perforation are : 

(a) Reduction of the intra-ocular tension. This symptom is par- 
ticularly valuable in the case of small wounds in the sclera, which are 
concealed by the ecchymosed conjunctiva, and are hence not directly 
accessible to inspection. The diminution of tension, of course, lasts 
only as long as the wound is open. 

(J) If the perforation has occurred in the region of the anterior 
chamber, the latter is shallower or altogether obliterated, until the 
wound closes. 

(c) In the case of somewhat larger wounds the prolapse of the 
subjacent structures gives evidence of the presence of a perforation. 
Most frequently it is the uvea which protrudes from the wound under 
the form of a darkly pigmented mass. According to the situation of 



DISEASES OP THE SCLERA. 233 

the wound, the prolapsed portion belongs to the iris, to the ciliary body, 
or to the chorioid. If the uvea is ruptured, some vitreous is often 
found hanging out of the wound. Very frequently, too, there are ex- 
travasations of blood in the interior of the eye, which, to be sure, often 
likewise occur in the case of non-perforating contusions of the eye. 
Blood extravasated into the anterior chamber generally sinks to the 
bottom of it soon after the occurrence of the injury, so that, like a 
hypopyon, it fills up the lowermost part of the chamber and is bounded 
above by a horizontal line (hyphcBma*). Blood in the vitreous often 
makes itself evident by a reddish reflex from the pupil (JmmopMhal- 
mus f ). 

Perforating wounds of the sclera are distinguished into incised, 
punctured, and lacerated wounds. To the two former belong, besides 
wounds produced by operation, those caused by the penetration of sharp- 
pointed or sharp-edged foreign bodies. Lacerated wounds are most 
frequently the consequence of a rupture of the sclera. This is produced 
by the action of a blunt instrument upon the eye (contusion) — e. g., by 
a blow with the fist or with a cane, by a stone, by the impact of large 
flying fragments of wood or metal, by a thrust from a cow's horn (not 
infrequent among farmers), by striking the eye against a projecting 
corner, etc. The rupture of the sclera is always pretty long, is curved, 
and lies near the corneal margin and concentric with it. Most ruptures 
are observed along the upper and inner margin of the cornea. As a 
rule, the process does not stop at laceration of the sclera, but a part of 
the contents of the eye, most generally the lens, is expelled, and the 
vitreous is sometimes seen hanging out of the wound. The iris, at a 
point corresponding to the site of the rupture, appears to be wanting, 
and the eye often looks as if the portion of the iris in question had 
been removed by iridectomy (see § 73). Frequently the conjunctiva 
over the lacerated sclera, thanks to its great extensibility, remains un- 
injured. In this case the extruded lens is sometimes found lying be- 
neath the conjunctiva (Fig. 66). 

The course after a perforating injury varies according as a foreign 
body has remained in the eye or not. Suppose, first, that no foreign 
body has remained in the eye. Then the only thing to be considered 
is the healing of the wound itself ; and in regard to this the main thing 
to determine is whether the injury has been followed by infection of the 
wound or not, as upon this depends the question whether healing takes 
place with or without inflammation. 

(a) Healing without inflammation is to be expected only in the case 
of clean, non-infected wounds. The most favorable conditions are pre- 
sented by clean incised or punctured wounds, such as, for instance, are 
made by operations, where at the same time care is taken that no foreign 



* From {nr6, beneath, and oT^a, blood. t P™™ '^l*"' ^^ooA, and 6(pea}^ixis, eye. 



234 



DISEASES OP THE EYE. 




tissue, like uvea or vitreous, is introduced into the wound. But even 
if this latter should be the case, healing without inflammation is still 
possible, although the edges of the wound can not unite with each other 
directly, because they are not in contact. The tissue consisting of uvea 
or vitreous introduced between them is gradually converted into cica- 
tricial tissue, and thus takes 
part in the definitive clos- 
ure of the wound. It then, 
to be sure, always remains 
attached to the cicatrix, a 
thing which later on often 
entails evil consequences. 
In this way — i. e., by the in- 
terposition of a cicatricial 
tissue taking place between 
the edges of the wound 
without inflammation — 
even lacerated wounds, such 
as develop, for example, af- 
ter rupture of the sclera, 
may, if the case runs a for- 
tunate course, heal, so that 
the eye remains serviceable 
for vision. 

We often observe that 
the scleral wounds, which 
lie near the corneal margin 
and in which the iris or lens 
capsule has become lodged, 
close imperfectly, owing to 
the fact that, while the con- 
junctiva does unite over the 
scleral wound, the latter re- 
mains open to a certain ex- 
tent because the interposed 
tissues prevent its lips from 
coming into direct contact. 
Through the gap aqueous 
humor constantly exudes 
beneath the conjunctiva, which either becomes oedematous in the 
region of the cicatrix or is bulged out in the form of a circumscribed 
vesicle resembling a cyst (Pig. 65, /*). Following Von« Graefe, we 
designate this condition as cystoid cicatrization (see page 124). It is 
chiefly observed after operations (cataract extraction and iridectomy). 
(5) Perforating wounds of the sclera are followed by violent inflam- 



Fio. 65.— Inclusion of the Iris with Cestoid Cicatri- 
zation AFTER THE EXTRACTION OF A SENILE CATA- 
RACT BY Graefe's Peripheral Linear Section. 
Enlargement 13 x 1. 

The section by which the extraction was made cuts in 
two the line of junction between the sclera, S, and 
tiie cornea, H, so that by its anterior half it lies in 
the sclera, by its posterior half in the cornea. On 
account of the interposition of the iris, /, the lips of 
the wound have not united ; in fact, the tract of the 
wound extends under the form of a cavity, 7i, even 
into the tissue of the conjunctiva of the limbus, L, so 
that the wound is closed only by a very thin la,yer of 
conjunctiva which, on account of the cavity beneath 
it, looks like a vesicle. The iris by being jammed 
into the wound is folded upon itself, the point of 
flexion corresponding to the exterior surface of the 
sclera. Peripherally from the site of its incarcera- 
tion the iris being drawn tense runs in ^ straight line 
to the ciliary body. C ; consequentl.y. the 'anterior 
chamber is here reduced to a narrow slit, although 
the sinus of the chamber remains pervious. On the 
other hand, the portion of the iris that extends cen- 
trally from the scar (pupillary portion of the iris) 
projects out into the anterior chamber, where it lies 
free. On its anterior surface may be seen the en- 
trance of a crypt, near its posterior surface the cross 
section of the sphincter pupillge. Besides the iris, 
the much-puckered capsule. A;, of the lens, is also 
drawn up to the cicatrix, and has become adherent 
to it. 



DISEASES OP THE SCLERA. 235 

mation -whenever infection of the wound or of the interior of the eye 
has occurred. Infection takes place either by means of the very body 
which causes the injury, it being covered with dirt and thus conveying 
infectious germs, or secondarily from the fact that the opening in the 
envelope of the eyeball afEords a point of entrance for germs, especially 
from the conjunctival sac. The interior of the eye is uncommonly sus- 
ceptible of infection, since it affords a good medium for the cultivation 
of diiierent kinds of schizomycetes. The inflammatory process mainly 
affects the uvea. In the acutest cases there is a purulent inflammation 
of the latter, which leads to suppuration of the whole eye (panophthal- 
mitis). In the less violent cases there is a plastic irido-cyclitis — i. e., 
the inflammation of the iris and ciliary body produces an exudate which 
subsequently becomes organized into a false membrane. In this case, 
too, the eye is generally lost, although it is not destroyed in such a vio- 
lent fashion as in panophthalmitis, but by a process of protracted in- 
flammation. The exudates which undergo organization shrink and 
thus gradually diminish the size of the eyeball (atrophy of the eyeball). 
This outcome of an injury is even more dangerous for the patient than 
panophthalmitis, since in the former case sympathetic inflammation of 
the other eye very frequently sets in, which is not the case in panoph- 
thalmitis. 

Foreign Bodies in the Eye. — The presence of a foreign body in the 
interior of the eye converts every injury, be it ever so insignificant 
otherwise, into a serious lesion, which, in most cases, entails the de- 
struction of the eye. Hence in every injury attended with perforation 
we must at once propound the query whether or not there is a foreign 
body left in the eye. In most cases the history of the case itself sup- 
plies points important for the determination of this fact. If, for in- 
stance, a person has run a pair of scissors into his eye, we would natu- 
rally suppose that there was no foreign body there ; conversely, in the 
case of a man who has had a perforating injury of the eye produced by 
the explosion of a percussion cap, or while he was hammering iron, 
the presence of a foreign body in the eye is extremely probable. The 
character of the foreign bodies in question varies exceedingly. Most 
commonly we have to do with fine splinters, the points and sharp edges 
of which enable them to penetrate the sclera. In this category belong 
chiefly splinters of metal, splinters of glass, and fragments of stone- 
less commonly slivers of wood, etc. The foreign body may be situated in 
any part of the eye ; indeed, if it has sufiicient projectile force, it may 
even, after traversing the entire eyeball, perforate the sclera a second 
time on the opposite side, and penetrate into the tissues of the orbit. 
The precise determination of the place in which a foreign body is 
located within the eye is generally attended with great difficulties. 
As a rule, it is only during the time immediately succeeding the injury 
that it is possible to see the foreign body directly, although even then 



236 DISEASES OF THE BYE. 

inspection of the interior of the eye is often rendered impossible by 
the presence of hemorrhages. Subsequently, the difficulty of this in- 
spection is still further heightened by the cloudiness which soon de- 
velops in the media and by the exudates which envelop the foreign 
body and render it indistinguishable. If we are dealing with metallic 
fragments of not too small dimensions, we may be able to make them 
out and localize them by means of the Eontgen rays ; and for chips 
of iron we may also employ a sensitive magnetic needle (sideroscope). 
If these means are unavailable, we are often driven to conjectures with 
regard to the location of the foreign body — conjectures based upon the 
direction pursued by the body in its flight, the situation of the aperture 
by which it entered, the sensitiveness of certain portions of the eye to 
touch, the presence of a circumscribed obscuration (scotoma) in the 
field of vision, etc. 

The consequences entailed by the presence of a foreign body in its 
interior almost always induce the destruction of the eye. It is only in 
rare instances that a foreign body is tolerated for any length of time in 
the eye without setting up infiammation, the body itself either remain- 
ing free or becoming encapsulated in an organized exudate. But even 
such eyes as these are by no means secure from a sudden outbreak 
of inflammation — occurring sometimes years afterward — which causes 
their destruction. In the great majority of cases the inflammation 
follows close upon the heels of the injury. Such an inflammation is 
either a panophthalmitis or a plastic irido-cyclitis, just as in the case 
of simple perforating injuries ; but when a foreign body remains in 
the eye it is of much more frequent — indeed, of almost constant — 
occurrence, and, besides, induces much oftener sympathetic disease of 
the other eye. 

The prognosis of perforating wounds of the eyeball is deducible 
from the exposition given above. In every case it is grave, for even 
the minutest prick made with a fine needle may induce suppuration of 
the eyeball, if the needle was contaminated with septic substances. As 
we do not for the most part know whether the body causing the injury 
was aseptic or not, and as the consequences of an infection of the wound 
do not set in until several days have elapsed, we must be very cautious 
in stating the prognosis during the first few days after the injury. In 
general, the nature of the wound, and the facts as to the presence of a 
foreign body in the eye, serve to determine the prognosis. With re- 
gard to the former, we must take into consideration the situation and 
extent of the wound, and the condition of its edges ; also whether or 
not the inner tunics of the eye have prolapsed into the wound, and how 
much, if any, vitreous has escaped. Large wounds with extensive pro- 
lapse of the inner tunics of the eye are always followed by inflammation 
and by shriveling of the eyeball. The question in regard to foreign 
bodies is often difficult to decide. If there is a foreign body in the eye 



DISEASES OP THE SCLERA. 237 

and it can not be removed at once, the eye is almost always lost. Again, 
in stating the prognosis, the danger which threatens the other eye, be- 
cause of sympathetic inflammation, must not be forgotten. 

54, Treatmeat. — When we get a recent perforating wound to treat, 
we must first try to determine whether a foreign body is probably pres- 
ent in the eye or not. 

(a) Suppose that there is no foreign body in the eye. Then the 
next inquiry that we make is whether there is or is not any prospect of 
preserving a serviceable eye. In the former case we put the patient im- 
mediately in bed, cleanse the wound from any dirt that may adhere to 
it, and disinfect it by irrigating with an antiseptic solution. If the 
iris has prolapsed into the wound, which can be the case only in wounds 
situated in the cornea or in the most anterior portions of the sclera, it 
must be carefully excised. But if the ciliary body or chorioid projects 
into the wound, they should not be removed, because, if they were, the 
vitreous would prolapse. Small wounds soon close of themselves by 
cicatrization ; large, gaping wounds should be united by sutures passed 
either through the edges of the sclera itself (only, however, through 
its superficial layers) or through the conjunctiva overlying it. 

In those cases in which, on account of the excessive extent of the 
injury, there is no prospect of retaining the eyeball in a serviceable 
condition, we advise the patient to have enucleation done at once. By 
this means he will be saved from a protracted illness as well as from 
sympathetic involvement of the other eye. 

In many cases it is impossible, even for one who has had great ex- 
perience, to determine beforehand whether an eye is going to be pre- 
served or not. It is then best to wait for some weeks, proceeding, how- 
ever, to enucleation as soon as the course takes an unfavorable turn. 
In the latter case, in any event, enucleation must not be put oil too 
long, as otherwise we might be caught unawares by an outbreak of 
sympathetic inflammation in the other eye. 

(b) If there is a foreign body in the eye, the latter is pretty surely 
lost unless the foreign body can be removed. Every endeavor must be 
made to accomplish this. For this object it is indispensably requisite 
to know, at least approximately, the situation of the foreign body. If 
the wound is still gaping and is large enough, we can pass a well-dis- 
infected instrument in through it, and endeavor to grasp the foreign 
body. If the wound is not adapted for this procedure, either because 
it has already closed up or because it presents unfavorable conditions 
on account of its size or position, it is better to make a new wound, 
located in the cornea or the sclera, according to the situation of the 
foreign body. In placing it in the sclera, the region of the ciliary body 
must be avoided ; the section must lie behind the latter, and is best 
made in a meridional direction (proceeding from before backward), 
since such wounds gape the least. Through the wound the instru- 



238 DISEASES OP THE EYE. 

ments are introduced in search of the foreign body ; but the operation 
of grasping and extracting it is often attended with great difficulty, 
and very frequently miscarries. The best prospect of success is afford- 
ed by foreign bodies in the anterior chamber, since we can be guided 
by sight in taking them out ; also by fragments of iron, for whose ex- 
traction we employ an electro-magnet. 

If there is no prospect of our being able to remove the foreign body, 
we may, as a matter of experiment, wait a while to see if possibly it will 
be tolerated by the eye without exciting inflammation. This is espe- 
cially apt to be the case when a foreign body is imbedded in the lens ; 
the latter becomes cloudy, and subsequently, when all the inflammatory 
symptoms have passed off, can be removed along with the foreign body 
contained in it by a cataract operation. As soon as plastic irido- 
cyclitis has set in, it is advisable not to make any more attempts at re- 
moving the foreign body ; absolutely the only indication in this case is 
enucleation. 

Injuries of the eye are very frequently followed by extrataaation of Wood into 
the interior of the organ — into the anterior chamber and the space occupied by 
the vitreous. Such extravasations are also observed apart from injury, as the 
result of inflammation or even without any known cause. In the anterior cham- 
ber, blood sinks to the bottom and is reabsorbed. In otherwise healthy eyes 
small quantities of blood may often disappear completely within twenty-four 
hours. The process of resorption lasts longer when there is much blood in the 
anterior chamber, and especially when the eye is diseased in other ways as well 
and its processes of tissue metamorphosis are not normal. The longer the 
blood remains in the anterior chamber, the darker does its color become. So, 
in cases in which a hemorrhage into the anterior chamber has been repeated 
after the lapse of some time, we see a hyphtema which is composed of two strata 
of different color; the lower dark stratum represents the first haemorrhage, 
the upper bright one belongs to the recently extravasated blood. Very old ex- 
travasations of blood sometimes acquire a brown or dirty-green color, and the 
cornea, too, may take on a similar coloration (see page 208). In the iris like- 
wise a greenish or brownish discoloration has been observed as a result of h£em- 
orrhage into the aqueous or vitreous chamber. 

If the blood remains a long time in the anterior chamber, it may— especially 
if there is a coexistent inflammation — serve as the substratum for the formation 
of new tissue. In this way the good result of operations, such as iridectomy 
and iridotomy, designed for the restoration of an unobstructed pupil, is often 
rendered of no effect, as the blood extravasated during the operation covers up 
the opening that has been made, and subsequently causes its reocclusion by 
means of a membrane. 

Blood extravasated into the vitreous is found there under the form of floc- 
culi or larger masses. "When observed with the ophthalmoscope, these either 
look simply black or show a faint reddish gleam. If they occupy the anterior 
section of the vitreous, they may even be recognized with lateral illumination 
(provided the pupil is widely enough dilated) through the dark-red reflex 
emitted from the depths of the eye. Blood occurring in the vitreous always 
requires a long time for its complete resorption ; and, if much blood has been 



BISBASBS OF THE SCLERA. 239 

extravasated, opacities of the vitreous of considerable size always remain and 
cause great impairment of vision. In some cases of traumatic hsemorrhages 
into the vitreous I have observed that, some time after the injury, the coloring 
matter of the blood all at once became dissolved in the ocular fluids and then 
was immediately diffused all through the eye. The aqueous humor, too, in 
such cases was colored red, so that the iris looked as though seen through ruby 
glass. 

Perforating injuries of the cornea are in general less dangerous than those 
of the sclera. It appears as if they were less readily infected, perhaps because 
the outflowing aqueous humor washes away again the germs that have been 
introduced into the wound. (For this reason ulcus serpens is observed mainly 
in consequence of superficial injuries of the cornea and not after deep perfo- 
rating wounds.) The greater danger of perforating wounds of the sclera may 
also be based upon the fact that by means of such wounds the ciliary body and 
the chorioid, which are very prone to become inflamed, are laid bare. Finally, 
the prolapse of the vitreous is also a factor very favorable to the production of 
infection, since this may be considered as representing a sort of natural cultiva- 
tion gelatin, in which micro-organisms thrive most luxuriantly. 

Vitreous that has been prolapsed through a wound gradually becomes clouded 
wherever it lies outside of the eye, so that it gets to look like a shred of mucus 
adhering to the region of the wound. It often takes several weeks before such 
a shred is finally cast off. 

Rupture of the sclera results from a blow striking the eye either directly or 
indirectly, a blunt body — e. g., the tip of a cow's horn— entering between the 
eyeball and one wall of the orbit and squeezing the eye against the opposite 
wall. The contents of the compressed eye are put suddenly in a condition of 
increased tension and thus cause rupture of the capsule of the eyeball. The 
rupture, therefore, takes place from within outward, and begins in the region of 
Schlemm's canal, because here the tough inner layers of the sclera pass over into 
the delicate lamellsB of the ligamentum pectinatum, and thus the resistance of 
the sclera is diminished at this point. Starting from Schlemm's canal the lacer- 
ation traverses the thickness of the sclera, running sometimes more or less per- 
pendicularly, sometimes obliquely backward. In the latter case the exterior 
aperture of the laceration lies some millimetres behind the margin of the cornea. 
The fact that most scleral ruptures start from a point situated upward and in- 
ward, is due to the trochlea, which forms a bony prominence at the upper and 
inner angle of the orbit (Figs. 165 and 166, T). When the eyeball is forced 
against either the inner or the upper wall of the orbit by a blow coming from 
below or from without, the trochlea presses into the sclera and thus causes the 
rupture to begin in this meridian (Miiller). 

Ruptures of the sclera are such serious injuries, because a force that is 
strong enough to break an eye open always causes lesians elsewhere in the inte- 
rior of the eye. The iris (Fig. 66, V) is almost always torn away from its in- 
sertion at a point corresponding to the extent of the scleral rupture (iridodia- 
lysis), and is either incarcerated in the wound or is extruded through the latter 
beneath the conjunctiva, to which it becomes adherent. The eye then presents 
a coloboma over an area corresponding to the rip in the sclera. The portion 
of the iris remaining in the eye is commonly found to be considerably retracted 
(Fig. 66, lower part). The anterior chamber is consequently unusually deep, 
and this is particularly the case if, in addition, the lens and a part of the vitreous 



240 



DISEASES OP THE EYE. 




Fig. 66. — Rupture of the Sclera akd Ltix- 

ATION OF THE LenS BENEATH THE CON- 
JUNCTIVA. Vertical section through an 
eyeball which had been injured by a 
calf's horn seven weeks before it was 
enucleated. Magnified 3x1. 

The rupture in the sclera lies close to the 
upper margin of the cornea, not quite 
one millimetre behind the corneo-scleral 
junction, so that the lower lip of the 
wouni contains a narrow rim of sclera. 
The tear in the sclera gapes to the extent 
of nearly a millimetre, and is filled with 
a delicate cicatricial tissue, a, which ex- 
tends back from this point into the inte- 
rior of the eye and envelops the ciliary 
body and the remains of the iris. The 
latter (6) lies at the lower edge of the 
rupture, rolled into a ball and recogniz- 
able as iris only through the retinal pig- 
ment it contains. The ciliary bod.y, c, 
likewise greatly altf^red, is found behind 
the upper edge of the rupture. It is con- 
tinued into the chorioid, rf, which pre- 
sents marked inflammatoi'y infiltration 
about the large blood-vessels. The ret- 
ina, e. is detached up to the ora serrata, 
and at the latter point is much puckered. 
Below the rupture is seen the cornea in 
section, compressed vertically and as a 
result of the compression puckered on 
its posterior surface. At the lower por- 
tion of the eyeball the ciliary body is 
swollen, and the iris is carried backward 
so as to be in part applied to the surface 
of the ciliar.y body. The detachment of 
the chorioid. rfj, and of the retina, Cj, 
seen here in the cut, did not exist dur- 
ing life, but is a result of the way the 
specimen was made. The scleral rupture 
is covered in front by a mass which 
from its concentric striation is recog- 
nized to be the lens. The conjunctiva, 
/, overlying the lens, is detached by it 
from the sclera as far as the limbus, g. 
h, remains of the conjunctiva at the 
lower margin of the cornea. 



have been expelled. In many cases a piece 
of the iris, or even the entire iris, is torn 
altogether out of the eye. In only a very 
few cases does the lens remain in the eye 
and in situ. . Usually it is either expelled 
entirely from the eye, or it remains lying 
beneath the conjunctiva, provided the lat- 
ter is unruptured (Fig. 66). The vitreous 
is often densely permeated witli blood; 
and laceration or hsemorrhagic detach- 
ment of the retina or chorioid may be 
present. Since to the severity of such 
lesions there is added the danger of sub- 
sequent infection of the wound, it can be 
readily understood that most eyes which 
have suffered a rupture of the sclera un- 
dergo destruction. It is an exception, in 
fact, for such an injury to recover with 
the retention of serviceable vision. A 
farmer once presented himself at my clinic 
who had been gored first in one eye and 
then, some years afterward, in the other 
also, by a cow's horn. In both eyes there 
was a healed-up rupture of the sclera to 
the inner side, with an apparent regular 
coloboma of the iris. Both lenses were 
absent, but the fundus was healthy and 
with cataract glasses the sight was very 
good. This man, therefore, may be said 
to have had a double extraction performed 
by the cow, and that, too, with more suc- 
cess than many operators are accustomed 
to have with their operations. 

For rupture of the cornea, see page 
202. 

The unfavorable prognosis which per- 
forating wounds of the sclera generally 
offer holds good, at least in part, even for 
those cases in which, to begin with, there 
is a smooth healing of the wound. Such 
eyes, which often recover from the injury 
with the restoration of good sight, never- 
theless not rarely become blind afterward 
because of secondary changes, which are 
the consequences of the cicatrix in the 
sclera. If the uvea is incorporated in the 
scar, it may be subjected to traction, and 
hence give rise to permanent symptoms 
of irritation ; repeated attacks of inflam- 
mation may start from the point where 



DISEASES OP THE SCLERA. 241 

the uvea is attached, and thus even sympathetic irido-cyclitis of the other eye 
may be set up. In scleral wounds which lie farther back, in the region of the 
retina, the latter may become attached to the cicatrix. By subsequent contrac- 
tion of the cicatricial tissue the retina is drawn more and more into the cicatrix, 
and thus is loosened from its bed ; the eye grows blind from detachment of 
the retina (Von Graefe). In this way, too, many eyes are destroyed which have 
been operated upon with apparently brilliant success by section of the sclera, 
as for the extraction of a foreign body or of a cysticercus. A further danger 
accrues to the eyes from the fact that the scleral cicatrices later on readily 
become ectatic, and lead to the formation of scleral staphylomata and also to 
increase of tension. 

The prognosis must be stated as almost absolutely unfavorable when a for- 
eign body has been left in the eye. A series of cases, to be sure, is known iu 
which a foreign body has been carried about in the eye for years without caus- 
ing injury. But, in comparison with the extreme frequency of such injuries, 
the number of these cases is inflnitesimally small ; and even in these cases the 
safety of the eye is by no means to be considered as permanently assured. As 
an example, the following case that I observed may be adduced : A young lady 
of twenty-five years of age was injured by the percussion cap of a child's gun 
exploding near her eye. A piece of the copper case of the cap penetrated into 
the left eye through the cornea ; it could be seen lying upon the lowermost 
part of the iris. The immediate consequence of the injury was an iritis, which, 
however, after some weeks got well, leaving several synechiffi. From that time 
on the eye remained free from inflammation and had good visual power. The 
piece of metal, which had a length of about one millimetre, could always be 
seen lying upon the iris, only it gradually assumed a black color. It was not 
until ten years after the injury that the sight began to diminish, and the patient 
was tormented by photopsia ; she also complained that objects directly looked 
at seemed to move and looked bent, so that straight lines, for example, appeared 
wavy to her. The eye was still free from inflammation, but, after rather pro- 
longed examination, showed a slight ciliary injection. Examination with the 
ophthalmoscope could not demonstrate any changes except that the fundus in 
its lower half was not as beautifully red as it was above, but was of a light 
grayish color. It was hence taken for granted that here was a detachment of 
the retina in its very earliest stage. The traction thus produced upon the retina 
accounted for the photopsia, and the undulatory movement of the retina ac- 
counted for the apparent movement of objects, while the curved appearance of 
straight lines was referable to the differences of level existing in the detached 
retina. Conjecturally the retinal detachment was produced by an old exudate 
which lay upon the ciliary body and the most anterior portion of the retina, 
and which by its gradual shrinking drew the retina farther and farther forward. 
Since then I have not had an opportunity of seeing the patient again, but the 
subsequent course of the case may be predicted with great probability. The 
retinal detachment will have become total; afterward an irido-cyclitis will have 
probably developed out of the condition of ciliary irritation of the eye, so that 
after some time the eye would become completely blind, would grow softer, 
and would be the site of frequently recurring attacks of pain and inflammation. 
Perhaps, too, the other eye would be attacked by sympathetic inflammation. 

Leber has determined, by a series of experiments upon animals, the reason 
why the presence of a foreign body in the eye regularly results in a severe in- 
16 



242 DISEASES OF THE EYE. 

flammation. This inflammation is either excited by the presence of micro-or- 
ganisms which make their way into the interior of the eye from the conjunctival 
sac, either along with the foreign body or subsequently, or it is the consequence 
of a chemical irritation of the tissues produced by those foreign bodies which 
are not chemically indiflEerent. For example, purulent inflammation could be 
produced by bits of copper, and still more by particles of mercury, which were 
introduced aseptically into the anterior chamber. Hence, such inflammation 
does not necessarily presuppose the penetration of schizomycetes into the eye. 
Observations upon man agree in general with the facts obtained by experiment. 
Whether a body which penetrates into the eye is well borne by it or not de- 
pends upon the following circumstances: 1. First of all, upon the fact of its 
being aseptic or not. 2. Upon its chemical character. Chemically indiflEerent 
bodies (such as, for instance, fragments of glass), if they get into the eye asepti- 
cally, are the ones most likely to remain there without producing any further 
ill effect. The contrary is true of the foreign bodies that are of most frequent 
occurrence — i. e., chips of metal. These almost always set up a severe in- 
flammation, which can not, however, in most cases be referred to their septic 
character. In fact, metallic chips (for instance, such as fly off while the metal 
is being hammered) are often raised to a red heat immediately before they 
penetrate into the eye, and are thus disinfected. They owe their property of 
exciting inflammation to the fact that they become oxidized in the tissues of 
the eye, and thus act as chemical irritants. This is the case with iron, and still 
more with copper; metals which, like lead and the noble metals, are innocent 
in this regard, are of comparatively rare occurrence in the eye. 3. The volume 
of the foreign body is of influence, inasmuch as the larger the foreign bodies 
are, the less readily are they tolerated ; for, while small foreign bodies speedily 
become flxed in the eye, larger ones readily undergo changes of place during 
movements of the eye, especially if they are of high specific gravity, as in the 
case with pieces of metal. By such displacements of the foreign body the sur- 
rounding tissues are mechanically irritated. 4. The individual tissues vary in 
respect to their tolerance of foreign bodies. The uvea, and especially the iris 
and ciliary body, exhibit the greatest reaction to injury of any kind. The lens, 
on the contrary, possibly on account of the sluggishness of its tissue metamor- 
phosis, is the part of the eye in which foreign bodies are relatively the best 
borne. If, for example, a small chip of iron has become imbedded in the lens, 
the latter, to be sure, becomes clouded, but inflammation ordinarily fails to take 
place. In such a case sometimes the lens is afterward colored brown by the 
oxide which is formed. A deep brown coloration is produced, mainly under 
the guise of rust-colored dots which lie beneath the anterior capsule of the lens, 
and form a crown, corresponding nearly in situation to the margin of the pupil 
when dilated (Samelsohn). Later the coloration may extend to the iris, which, 
if previously gray or blue, assumes a rusty brown hue. This impregnation with 
iron also occurs in the other tissues of the eye, particularly in the retina, which 
may in consequence become atrophic, so that blindness may ultimately ensue 
even when the fragment is tolerated without inflammation (Hippel, Jr.). The 
impregnation of the tissues with iron is called niderosis bulbi (from a-idrjpos, 
iron). 

Small fragments of iron may in time be entirely dissolved by oxidation. 

Perforating injuries of the eye are very frequent in the working class, and 
furnish a large contingent of the blind. This is particularly the case in regions 



DISEASES OF THE SCLERA. 243 

where many industries are carried on. The following report of Cohn gives a 
good idea of the frequency of the injuries to which the eyes of many workmen 
are exposed : Among twelve hundred and eighty-three workers in metals em- 
ployed in six factories, each man received on an average from two to three eye 
injuries in a year. Of course, the great majority of these injuries were of a 
slight character; most, indeed, consisted merely in the penetration of small 
metallic particles into the surface of the cornea, which were, for the most part, 
removed at the factory itself. About half of the workmen were compelled to 
seek medical aid ; and out of every thousand 28 suSered a partial impairment 
of sight, and 16 had lost one eye altogether. 

Is there, then, no protection against these frightfully frequent injuries of 
the eyes ? Certainly, and moreover a very simple one — namely, the wearing of 
protective spectacles. These are made of glass, or, that they may not be easily 
broken, of mica or of fine wire net. Unfortunately, the use of these protective 
spectacles has, up to the present time, always encountered great opposition on 
the part of the workmen who require them. 

The attempt to remove the foreign body which has penetrated into the eye 
is often beset with great difficulties, and very frequently is unsuccessful. No 
fixed rules can be laid down for the procedures to be employed for this purpose, 
as almost every individual case has its peculiarities and calls for an operation > 
devised specially for itself. 

In injuries produced by chips of iron, the magnet is employed. Forms of 
apparatus have been constructed to determine in doubtful cases whether a piece 
of iron is present in the eye at all. In these the injured eye is brought as close 
as possible to a very sensitive magnetic needle (astatic needle of L6on Gerard, 
sideroscope of Asmus) which undergoes deflection if there is a chip of iron 
present in the eye. By ascertaining at what point of the surface of the eyeball 
this deflection is the greatest, we can determine approximately the situation, of 
the iron. 

Much more frequently the magnet is employed for removing the foreign 
body. The extraction of a chip of iron from the vitreous by means of a bar 
magnet introduced tlirough an incision on the sclera was first performed by 
MacKeown (1874). Hirschberg constructed the first available electro-magnet, 
wliich is the form now commonly employed. About a rod of soft iron is wound 
a spiral coil of copper wire, not too thin, the two ends of which are connected 
with a powerful galvanic element. The ends of the iron rod, which project 
somewhat beyond the spiral, are a little bent and end in a blunt point, adapted 
for introduction into the interior of the eye. For this latter purpose we enter 
either through the wound itself, in case this is large enough and is still open, 
or we make an incision in a suitable situation in the cornea or sclera, according 
to the location of the foreign body. Recently very powerful electro-magnets 
have been used (Haab, Schloesser). These are not introduced into the eye, but 
are merely applied to it exteriorly, as they are able to attract even small frag- 
ments of iron when at some distance from them. It is not often that the point 
of entry of the iron chip is a proper place to apply the magnet to, in order to 
extract the fragment from the eye. Generally, it is better to place the tip of 
the magnet against the center of the cornea, so as to bring the fragment through 
the pupil and into the anterior chamber, from which it may then be removed 
by an incision made at the margin of the cornea. The large have the follow- 
ing advantages over the small magnets: (1) It is not necessary to make a 



244 DISEASES OF THE EYE. 

wound in the sclera ; (3) the situation of the fragment need not be known pre- 
cisely ; (3) even very small fragments can be removed in this way. 



III. Ectasia of the Sclera. 

(a) Partial Ectasia. 

55. Partial ectasia of the sclera is represented by a circumscribed 
protrusion taking the form of a dark prominence or swelling. The 
sclera at this spot is thinned, so as to be readily dimpled with the point 
of a sound ; in consequence of the thinning, the chorioidal pigment 
appears through it, and imparts to the ectasia a dark, slate-gray, or 
bluish-black color. By means of focal illumination, light can often be 
made to pass through the sclera at the ectatic spot, and the coating of 
pigment on its inner surface can be seen through it. According to 
the situation of the ectasia, various forms of it are distinguished — 
namely : 

1. Anterio?- Ectasim (anterior scleral staphylomata). — These occupy 
the portion of the sclera adjoining the cornea (Figs. 67 and 68). They 
appear in the beginning under the form of small, dark spots, which 
afterward become larger and bulge out. When several lie close together 
they become confluent, forming a large swelling which surrounds 
the cornea like an arch or ring. This swelling at various points is con- 
stricted in a radial direction by the stronger, less distended fibers of 
the sclera, so that in a small way it resembles the large intestine with 
its sacculations. The limbus, under the form of a somewhat depressed 
gray line, marks the boundary between the ectasia and the cornea. 
When the latter is also opaque and ectatic, the sharp line of demarca- 
tion between scleral and corneal ectasis is often lost, and both ectasise 
unite to form a single protuberance occupying the anterior segment of 
the eyeball. It often happens that an anterior scleral staphyloma 
exists, or, at all events, has its chief development, on one side only. 
Then the base of the cornea at this side is pushed forward, so that the 
entire cornea gets to lie obliquely. If, for instance, the scleral staphy- 
loma occurs on the inner side, the cornea looks outward instead of 
straight forward (Fig. 68, h). 

2. Equatorial Ectasim (equatorial staphylomata).— These are dark 
prominences in the region of the equator of the eyeball. They can be 
seen only when the eyeball is turned strongly toward the side opposite 
the staphyloma. They occur at either one or more spots upon the 
equator, but never surround the entire eyeball like a ring, as is fre- 
quently the case with anterior scleral staphylomata. 

3. Posterior Ectasice.—These occupy the posterior segment of the 
eyeball, and can not, therefore, be seen in the living eye. In respect 
to origin and significance, they are essentially distinct from anterior and 
equatorial staphylomata of the sclera. There are two kinds of posterior 



DISEASES OP THE SCLERA. 



245 



scleral ectasiis : a. The staphyloma posticum Scarpm. This consists in 
a thinning and protrusion of the sclera at the posterior pole of the eye 
to the outer side of the optic-nerve entrance. If the ectasia takes ou 
greater dimensions, the optic nerve is also involvedin it (Fig. 221). This 
form of ectasia, as Arlt was the first to discover, is the most frequent 
cause of short-sightedness, because owibg to the recession of the sclera 
the eyeball undergoes an elongation of its sagittal axis (axial myopia). 
The diagnosis of a posterior staphyloma can be made in the living eye 
only by demonstrating the existence of a high degree of myopia and of 
the accompanying changes in the opthalmoscopic picture (§ 77). /3. 
Posterior scleral protrusioti of Amman. This does not, like posterior 
staphyloma, lie just at the posterior pole, but below it. Contrary to the 
case of the other ectasite of the sclera, it is not acquired but congenital, 
being formed in consequence of an incomplete closure of the foetal 
ophthalmic cleft. It is found simultaneously with the formation of a 
fissure (coloboma) in the chorioid and frequently, also, with coloboma 
of the iris (see §§ 76 and 80). 

Acquired ectasise of the sclera are designated under the name of 
staphylomata of the sclera, as has been done in the preceding lines, but 
the expression staphyloma is not applied to the congenital scleral pro- 
trusion of Ammon. 

(h) Total Ectasia of the Sclera. 

This consists in a uniform dilatation of the entire sclera, so that the 
eyeball is enlarged in toto. The sclera is everywhere thinned and the 
chorioidal pigment shows through it, so that it has a bluish-white appear- 
ance. Total ectasia can develop only in youth when the sclera is still 
everywhere yielding ; the sclera of adults is so rigid that it can protrude 
only at certain weaker spots, and hence it admits of only partial ectasise. 
Total ectasia occurs most frequently at the same time with staphyloma 
of the cornea or with anterior scleral staphyloma. By the combina- 
tion of these two kinds of ectasia a very extraordinary enlargement 
of the eyeball sometimes develops. Much more rarely a second, pure 
form of scleral ectasia is observed, in which the eye shows simply a 
uniform enlargement in all its dimensions — an enlargement in which 
the cornea also participates (megalocornea). This condition is charac- 
terized as hydrophthalmus or buphthalmus (/3o{)s, ox, on account of the 
resemblance to the large eyes of oxen). Hydrophthalmus is either con- 
genital or is acquired in early childhood, and is probably analogous to 
the glaucoma of adults, under which disease, therefore, hydrophthal- 
mus will be treated of in detail (see § 83). 

Etiology. — Every ectasia of the sclera is the result of a dispropor- 
tion between the intra-ocular pressure and the resistance of the sclera. 
Either the tension of the eye is pathologically heightened or the tenac- 
ity of the sclera is diminished. The former is much the more fre- 



246 DISEASES OP THE EYE. 

quent cause of scleral ectasise (if the posterior ectasias are excepted). 
Scleral ectasiae develop slowly, and the disproportion between the ten- 
sion of the eye and the resistance of the sclera must persist for a 
pretty long time before it can make the sclera become ectatic. 

(a) The result of elevation of the intra-ocular tension is that every 
square millimetre of the interior surface of the sclera has to bear the 
same increase of pressure. If the sclera possessed the same constitu- 
tion throughout it would, in case it yielded to the pressure at all, ex- 
pand in a perfectly uniform fashion. But some portions of the sclera 
are constructed less solidly than others, and these give way first to the 
increased pressure. These less tenacious spots are those in which the 
sclera has nerves or vessels passing through it into the interior of the 
eye, and in which, therefore, it is perforated and thinned. Chief among 
these places is the lamina cribrosa, and next those portions of the sclera 
where the venae vorticosae and the anterior ciliary vessels perforate it. 
At the site of the lamina cribrosa the sclera is reduced to a thin mem- 
brane, which is riddled with holes like a sieve, and which, under in- 
creased pressure, bulges out backward. This bulging, however, is not 
counted among the staphylomata of the sclera, but is designated as an 
excavation of the optic nerve, because the head of the optic nerve 
recedes simultaneously with the lamina cribrosa (§ 81). Equatorial 
staphylomata develop at those spots where the venae vorticosaB perforate 
the sclera and anterior scleral staphylomata at the spots where the 
anterior ciliary vessels are transmitted. The other, more resistant sec- 
tions of the sclera remain unchanged, even under increased intra-oeu- 
lar pressure ; it is only in children, in whom the sclera is capable of 
expanding as a whole, that total ectasia develops. 

The most frequent causes of the elevation of intra-ocular pressure 
are glaucoma, seclusio pupillae, and ectatic cicatrices of the cornea. 
In glaucoma, in which the venae vorticosae are the main seat of 
congestion and inflammation, equatorial staphylomata generally de- 
velop ; seclusio pupillae and staphylomata of the cornea, on the con- 
trary, in which the inflammation expends itself upon the most an- 
terior sections of the eyeball, mostly induce anterior ectasise of the 
sclera. < 

{I) The result of diminished resistance of the sclera may be that 
the latter is unable any longer to withstand even the normal intra- 
ocular pressure. Diminished resistance develops in consequence of 
inflammations of the sclera, and hence occurs in the deep form of 
scleritis, which leads to anterior scleral ectasiae (page 239) ; it also 
occurs when tumors (malignant new growths, gummy or tuberculous 
nodules) develop in or beneath the sclera. Injuries of the sclera 
also diminish its tenacity, and hence the cicatrices after penetrating 
wounds (and especially after ruptures) of the sclera very frequently 
become ectatic. Scleral ectasiae arising in this way lead subsequent- 



DISEASES OP THE SCLERA. 24T 

ly to elevation of the intra-ocular pressure, which then, however, 
must be regarded not as the cause, but as the result of ectasis, even 
though it does contribute to make the latter still larger. Here, then, 
the same process that occurs in ectasise of the cornea (page 215) is 
repeated. 

Posterior scleral ectasise are likewise referred to a diminution in 
the resistance of the sclera. With regard to the development of 
staphyloma posticum, the cause of it is assumed to be a congenital 
weakness of the sclera in its posterior portion. With respect to Ani- 
mon's scleral protrusion, the idea is held that the foetal ophthalmic 
cleft is filled up with a sort of intermediary tissue which does not 
possess the firm texture of the normal sclera, and hence gives way be- 
fore the ocular pressure. 

Consequences of Scleral Ectasise. — In anterior and equatorial staphy- 
lomata of the sclera the sight is at length completely destroyed through 
rise of tension. If the ectasia does not come to a stop, the enlargement 
of the eyeball keeps growing greater and greater. The eyeball projects 
far beyond the palpebral fissure, can be covered but incompletely by 
the lids, and is extremely disfiguring. Conjunctival catarrh, lachryma- 
tion, and blepharospasm develop as a result of the mechanical irrita- 
tion, and not infrequently the lower lid is pushed so far out by the 
enlarged eyeball as to be everted (ectropion). Finally, some light 
injury suffices to cause the rupture of the staphyloma at a particularly 
thinned-out spot. The greater part of the liquefied, vitreous is evacu- 
ated, and in consequence a violent haemorrhage may take place, and 
the eye may undergo destruction with the symptoms of panophthal- 
mitis. 

Staphyloma posticum, if it enlarges, causes a considerable increase 
in the short-sightedness, without, however, inducing elevation of ten- 
sion and the other deleterious consequences of anterior and equatorial 
staphylomata. The scleral protrusion of Ammon remains stationary 
and entails no injurious consequences. 

Treatment. — It is only anterior and equatorial, not posterior, ectasias 
of the sclera that are amenable to treatment. In the former, which, 
in the great majority of cases, have developed in consequence of an 
increase of tension, the main indication is iridectomy, provided that 
it is still technically practicable. Inasmuch as this operation dimin- 
ishes the intra-ocular pressure, it puts a stop to the further enlarge- 
ment of the scleral ectasiae (and in especially favorable cases even causes 
diminution in the size of an ectasia already existing), and likewise pre- 
serves the sight, so far as it still exists, from total destruction. If, as 
indeed is generally the case, iridectomy is on technical grounds no 
longer practicable, there is nothing else left to do but enucleation, in 
case the eye distresses the patient by its size, its painfulness, or the 
disfigurement it causes. 



248 



DISEASES OP THE EYE. 



The anatomical structure of scleral staphyloma is essentially different from 
that of staphyloma of the cornea. While the latter consists of cicatricial tissue 
which replaces the cornea that has been destroyed, a scleral staphyloma is formed 
of the sclera itself, which has not ceased to exist at the site of the ectasis, but is 
simply thinned, so that often it is no thicker than a sheet of paper. In posterior 
staphyloma the thinning is uniform ; in anterior and equatorial staphylomata we 
often find that the thinning is not uniform, and commences suddenly, owing to 
the abrupt disappearance of the inner layers of the sclera at the margin of the 
ectasis. The sclera then in the spot where it bulges looks as if it had been 
gnawed into from the inner side, and thus deprived of its innermost layers. Prob- 
ably this is owing to the fact that the innermost layers of fibers of the sclera, in 
consequence of the great stretching to which they are exposed, first rupture at 
some spot and then gradually separate from each other (Czermak and Bim- 
bauher). The uvea is always solidly adherent to the inner surface of the ectasia, 
and is here so atrophic that scarcely anything is left of it but its pigment layer, 
which forms the dark coating of this inner surface. 

Dissection of ectatic eyeballs shows that anterior scleral staphyloma may be 
of two kinds — ciliary or intercalary staphyloma. The former (Fig. 67) belongs 





Fig. 67.— Staphyloma Ciliare. (After Pagenstecher.) 

The eye is bisected horizontally. Surrounding the cornea there is an ectasia, o, of the sclera, 
which attains its greatest breadth at the tetnporal side, t ; and on the nasal side, n, is nar- 
rower and less prominent, for which reason the cornea appears displaced toward the nasal 
side. The inner surface of the ectasia is coated with the elongated cihary processes • the 
iris is invisible because it is pressed against the posterior surface of the cornea which hence 
looks pigmented in black. The retina and chorioid have been to some extent separated from 
their bed b.y the dissection ; in the retina, groups of punctate haemorrhages b are observ- 
able. The head of the optic nerve, o, shows a deep excavation due to pressure.' 

Fig. 68.— Staphyloma Intebcalaee. 
The eyeball is horizontally bisected and is drawn of somewhat more than the natural size The 
ectasia, s, of the sclera is interposed on the nasal side, n. between the cihary body, c, and 
the cornea, h, so that the latter is displaced toward the temporal side. The inner surface of 
the ecta-sia is covered with pigment, representing the remains of the root of the iris which 
has become adherent to the thinned sclera : this pigment, in consequence of being spread 
over so large a surface, shows numerous gaps. Toward the outer side the ectasia con- 
stantly diminishes in breadth, so that, at the spot where the temporal wall of the eye- 
ball, t has been cut through, nothing but a very narrow interspace is observable between 
the cihary body and the ins, a condition due to that agglutination of the root of the iris to 
the sclera which characterizes an increase of tension. In the bisected optic nerve, the nor- 
mal conical contraction of the intra-scleral section, i, can be recognized : and in the retina 
can be seen the fovea centralis, /, and the expansion of the retinal vessels. 

to that part of the sclera, the inner surface of which is coated by the ciliary body; 
the latter (Pigs, 68, 69), on the other hand, develops in that narrow portion 
of the sclera which is situated in front of the ciliary body, between it and the 
margin of the cornea; for the anterior border of the ciliary body, and hence, 



DISEASES OF THE SCLERA. 



249 



too, the root of the iris, as it springs from the ciliary body, do not correspond 
precisely to the sclero-corneal junction, but lie somewhat behind it — that is, the 
most anterior portion of the sclera, which lies in front of the root of the iris, be- 
longs to the anterior chamber. But, although it is just in this portion that an 
intercalary staphyloma develops, the iris does not lie behind the latter but in 




Fig. 69.— Intercalary Staphyloma. Magnified 4x1. 

The figure represents a vertical section through the anterior half of the ectatic eyeball, which 
presents a great resemblance to the eye shown in Fig. 68, except that the most marked 
ectasia in the present case is situated above the cornea. The limits of the cornea are 
marked by the linibus I and Ij. At Z may be seen how the root of the iris is apphed to the 
sclera ; and the beginning of a process of thinning in the sclera can be made out. while on 
the other side of the eye there is a fully developed mtercalary staphyloma, which extends 
frorn a to 6, and which in the living eye formed a dark translucent prominence. In the 
region of the staphyloma the sclera is reduced to half its normal thickness, and its inner 
surface is covered with a thin pisment coating representing the rnmains of the iris. The 
iris is adherent to the sclera from the ciliary body, a, to the anterior border, b, of the ectasia. 
The ciliary processes, owing to atrophy, are flatter than normal. 



front of it, just as in the case of ciliary staphyloma. This comes to pass in the 
following way : The formation of the ectasia is preceded by increase of tension, 
which causes the most peripheral portion of the iris to be pressed forward and 
to become united with the sclera (see § 84 and Figs. 118 and 119). Hence that 
pait of the iris lying free in the anterior chamber is given off from the sclera at a 
point farther forward tlian usual. Looked at with the naked eye, it seems as if 
the insertion of the iris had been pushed forward, up to the scloro-corneal junc- 
tion or beyond it. Now, an intercalary staphyloma develops precisely in that 
region of the sclera which is united with the periphery of the iris — i. e., at I in 
Fig. 69, where the beginning of such an ectasia may be made out from the fact 
that just in front of the point where the iris is given off the innermost lamellES 
of the sclera have separated and the iris has been pushed into the gap. Hence 
the ectasia always lies between the real origin of the iris at the anterior border 
of the ciliary body and its apparent origin at the spot where the portion of the 
iris that is yet free commences; and does so still even when it gets to be as 
large as represented on the left side of Fig. 69 (between a and h). The inner 
surface of an intercalary staphyloma is coated with a layer of pigment, which is 
nothing but the completely atrophic root of the iris that has become united to 
the sclera. 

In an eyeball which has not been dissected, the distinction between a ciliary 
and an intercalary staphyloma is more difficult to effect than in an anatomical 
specimen, but may still be made from the following diagnostic points: In 
intercalary staphyloma the anterior ciliary vessels are seen emerging from the 



250 DISEASES OP THE EYE. 

sclera at the posterior border of the ectasia, in ciliary staphyloma at its anterior 
border. A thin ciliary staphyloma usually transmits light, and so admits of our 
recognizing the elongated ciliary processes as black strise on its inner surface 
(c, Fig. 67). 

Ectasis of the sclera usually entails still further changes in the interior of 
the eyeball. In consequence of the enlargement of the ring formed by the ciliary 
body, the iris becomes stretched and atrophic, and may even in places be sepa- 
rated from its insertion (spontaneous iridodialysis). The same is true of the 
zonule of Zinn, which, through atrophy, gets to be so deficient that the lens be- 
comes tremulous or even undergoes luxation. The ciliary body, chorioid, retina, 
and optic nerve become atrophic ; the latter generally presents a deep excava- 
tion due to the increase of tension (o, Fig. 67). 



TJlcebs akd Tumors of the Sclera. — The sclera is not very apt to become 
inflamed, and still less are the products of its inflammation apt to undergo 
purulent disintegration; thus, for example, ulceration of scleritic nodules is 
never observed. Ulcers which originate in the adjacent part of the cornea are 
always arrested as soon as they reach the sclera; nor are ulcers of the con- 
junctiva any more likely to extend to the sclera beneath them. Hence ulcers 
in the sclera are among the greatest of rarities. They originate from injuries 
associated with infection and also from the disintegration of new growths (gum- 
mata, tuberculous and leprous nodules, malignant new growths). 

New growths, too, occurring primarily in the sclera are extremely rare; 
although, of course, tumors originating in other parts of the eye do pass over to 
the sclera. Fibromata, sarcomata, and osteomata are the primary tumors that 
have been observed in the sclera. 



CHAPTER IV. 

ANATOMY AND PHYSIOLOGY OF THE UVEA, 
EMBRYOLOGY OF THE EYE. 

I. Anatomy. 

56. If we carefully remove the sclera and cornea from an eyeball, 
we have presented to us the iris, ciliary body, and chorioid in connec- 
tion. Together these form the middle tunic of the eye, which takes 
the shape of a sphere, colored dark brown by the pigment which it 
contains. In front this has a large aperture, the pupil; behind it 
has a small one, the opening designed for the transmission of the optic 
nerve. On account of the similarity of the dark sphere, hanging upon 
the optic nerve as upon a stalk, to a grape {uva), the middle tunic of 
the eye has received the name of uvea, and also of uveal tract. 

(a) Iris. 
The iris * is a disk-shaped membrane, perforated in the center by 
the pupil.f By its peripheral or ciliary border it springs from the 
anterior surface of the ciliary body. Prom this point it stretches over 
the lens, its central or pupillary border lying upon the anterior capsule, 
and gliding upon it with the movements of the pupil (Pig. 71). By 
lying in this way upon the lens, the iris obtains a firm support. Hence, 
when the lens is absent or has lost contact with the iris, the latter is 
seen to tremble or vibrate with movements of the eyeball (tremulous- 
ness of the iris, iridodonesis J). Since the umbo of the lens lies farther 
forward than the spot where the iris originates in the ciliary body, the 
iris forms a shallow cone, whose apex, directed forward, is cut off short 
by the presence of the pupil. The shallower the anterior chamber 
becomes through advancement of the lens, the greater is the altitude 
of this cone ; if, on the other hand, the lens is absent, the iris extends 
in a plane. 

* Iris on account of its rainbow shape, not on account of its color. 

+ Pupilla properly means girl ; perhaps so called because in the pupil one sees 
a diminutive image of himself reflected from the cornea. So, also, in old German 
works the pupil is named " Kindlein " (= little child). In Greek, too, the pupil is 
called K(<pj), girl, from which the expressions coreotopia, oorelysis, etc., are derived. 

% From iris and Soveo/iai, I vibrate. 

251 




252 DISEASES OE THE EYE. 

In looking at the iris with the naked eye, or, still better, with the 

magnifying glass, we recognize in its delicate markings, which are 

formed by elevations and depressions of its anterior surface (relief of 

the iris, Fig. 71). Sharp and clear in the normal eye, these markings 

are blurred or absolutely indistinguishable in an inflamed or atrophic 

iris, so that they constitute an important sign in iridic affections. The 

markings are chiefly formed by radially 

directed, projecting ridges, which are 

nothing but the blood-vessels lying in 

the stroma of the iris, and running from 

the ciliary to the pupillary margin. 

Near the latter they interlace with a 

ring of circular ridges — the lesser circle 

(circulus minor) of the iris {k. Fig. 70). 

Fio. 70.-A.NTEEioa Surface of the This latter divides the iris into two 
IRIS. Magnified 6 XI. ^^^^^^ . ^^^^ , . ^^ ^^^ periphery of 

P, pupillary zone; C, ciliary zone ; r, . . • ii •l■ 
fringe of retinal pigment ; /c, lesser the Circulus minor is the ciliary zone 
circle; c, crypt; /, contraction ,^> ,, , i ■ . .1 j. 1 -j j; 
groove ; re, nasvus ; p, peripheral ( 6 ) ; that lying tO the central Side 01 

it is the much narrower pupillary zone 
(P), which is often distinguished from the ciliary zone by a different 
coloration. Along the circulus minor may be noticed pitlike depres- 
sions (crypts, c) in the surface of the iris. Similar but much smaller 
openings in the anterior surface also exist at the periphery of the iris, 
close to its root ; but these are not perceived in the living eye, partly 
because they are too small, partly because they are concealed by the 
margin of the sclera, which projects in front of them. It is only in 
blue eyes, especially in children, that this peripheral perforated zone 
becomes apparent as a dark, almost black, circle {p) close to the root 
of the iris. The pupillary margin of the iris is seen to be lined by a 
narrow black fringe (r), which stands out with especial prominence 
in eyes affected with cataract ; for it contrasts much more forcibly with 
the white background of the clouded lens than with the black of the 
pupil of a normal eye. 

Microscopical Anatomy. — The stroma of the iris consists essentially 
of numerous vessels running in a radial direction from the ciliary to 
the pupillary margin. The vessels are inclosed in a thick adventitia, 
and are surrounded by a loose meshwork of branched and pigmented 
cells, which fill up the interspaces between them. The vessels, together 
with the cellular meshwork, form the stroma of the iris, which conse- 
quently is a very loose, spongy sort of tissue. Close to the pupillary 
margin of the iris the muscle which closes the pupil — the sphincter 
iridis — is found imbedded in the stroma (Fig. 71, sp). This is a flat 
band of smooth muscular fibers, one millimetre broad, lying close to 
the posterior surface of the iris. 

On the anterior surface of the iris there is a specially dense layer 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 253 

of cells (anterior limiting layer, Pig. 90, v). Next to this is a layer of 
endothelium, which is a continuation of the endothelium of Descemet's 
membrane, and covers the entire anterior surface of the iris as far as 
the pupillary margin. It is deficient only at those spots which corre- 
spond to the crypts, including both those at the pupillary (Fig. 71, cr) 
and those at the ciliary margin (c, c). These crypts, therefore, form 
apertures which lead into the interior of the tissue of the iris and place 
its tissue spaces in free communication with the cavity of the anterior 
chamber. This arrangemen': lavors the rapid change in volume of the 
iris in the alternating movements of the pupil, since it enables fluid to 
pass rapidly from the tissue of the iris into the anterior chamber and 
vice versa. 

The posterior surface of the stroma of the iris is covered by the 
posterior limiting membrane and the retinal pigment layer. The for- 
mer (Fig. 90, h) consists of very even, tense fibers, which extend in a 
radial direction from the ciliary to the pupillary margin, and hence 
have been regarded as a dilator pupillae. Physiologically speaking, 
the function of a dilator does really belong to the posterior limiting 
membrane, since the pupil is actively dilated by its contraction. Prob- 
ably, however, this is a case not of muscular but of elastic traction. 
To the posterior limiting membrane succeeds the retinal pigment 
layer, which coats the posterior surface of the iris. It extends to the 
pupillary margin, round which it turns so as to appear a little on the 
anterior surface of the iris (Fig. 71, at jo), and so forms that black 
rim which we perceive along the pupillary margin, when looking at 
the eye from in front. The pigment layer consists of two strata of epi- 
thelial cells (v and A, Fig. 71, and c and d, Fig. 72), which merge into 
each other at the pupillary margin. The two together, as embryology 
teaches us, represent the continuation of the retina to its termination 
at the pupillary margin (Fig. 89). This layer of the iris is therefore 
designated as the retinal layer (pars retinalis iridis sive pars iridica 
retinse), in contradistinction to the anterior layers, which, as they be- 
long to the uvea, are comprised under the name of pars uvealis iridis 
(Schwalbe). 

The color of the iris, which is either light (blue or gray) or dark 
(brown), is caused by the iridic pigment. There are two kinds of pig- 
ment in the iris : one lies in the branched cells of the stroma, and is 
hence called the stroma pigment ; the other fills up the epithelial cells 
of the retinal pigment layer (retinal pigment). Upon the proportion 
between the amount of pigment deposited in these two the color of the 
iris depends. The retinal layer of the iris always abounds in pigment, 
while the amount of stroma pigment that the iris contains varies greatly. 
When the stroma contains little pigment, the retinal pigment shows 
through the thin iris, and appears blue. This is due to the same phe- 
nomenon that causes a dark background always to appear blue when 



ANATOMY AND PHYSIOLOGY OP THE UVEA. 255 

looked at through a more or less opaque medium. Thus, for instance, 
through a delicate skin the veins look blue. If the stroma is deficient 
in pigment, but pretty thick and compact, the iris appears gray. And, 
finally, the greater the amount of brown stroma pigment that the iris 
contains, the more this pigment becomes visible and makes the iris ap- 
pear of its own brown color, while the retinal pigment layer, which lies 
behind, is more and more concealed by the stroma pigment and with- 
drawn from view. 

Not infrequently in an iris, that is but slightly pigmented as a 
whole, one or two isolated accumulations of pigment are found in 
the stroma. These then stand out as dark (rust-colored, brown, or 
black) spots in an otherwise gray or blue iris (nasvi iridis, Pig. 70, n). 
The presence of a pretty large number of them gives the iris a mottled 
appearance. 

Exceptionally, cases occur in which the iris has no pigment either 
in its stroma or in its retinal layer. Such an iris is found in albinos ; 
it is translucent, and, on account of its numerous vessels, has a deli- 
cate, grayish-red color. 

The examination of the iris in the living eye shows us, besides the details 
of relief mentioned above, a number of concentric curved lines near the ciliary 
margin of the iris (/, Fig. 70). They are particularly well seen in a dark iris 
with a contracted pupil, when by their light color they show ofi well upon the 
brown background. These are the contraction furrow% of the iris; so called be- 
cause, as the iris becomes narrower during the dilatation of the pupil, its an- 
terior surface is disposed in folds, and depressions between the folds (/, /, Fig. 
71) form the furrows in question, at the bottom of which the stroma of the iris 
generally contains less pigment. When the pupil contracts, these folds are 
smoothed down, and the furrows open out and are then easier to be seen. 

With the varying dilatation and contraction of the pupil we also notice a 
change in the rim of pigment upon the pupillary margin : the more contracted 
the pupil is, the broader this becomes ; on the other liand, when the pupil is 
strongly dilated, it disappears entirely. 

When the pupil is very much contracted, we not infrequently observe even 

Explanation op Fig. 71. — Meridional Sectfon through the Anterior Portion of the 
Eye. Magnified 16 x 1. — The boundary between cornea, C and sclera, S, is marked at its pos- 
terior surface by the cross section of Schlemm's canal, s- Anteriorly it is covered by the limbus 
conjunctivse, Z- ; farther back the cross section of an anterior ciliary vein, cz, is seen in the 
sclera. The iris is attached by the lig:amentum pectinatura, Z, to the inner posterior wall of 
Schlemm's canal. On the anterior surface of the iris may be recognized tlie orifices of the 
crypts both in the circulus minor i.cr) and in the periphery (c), also tlie contraction furrow,/. 
The posterior surface of the iris is covered with a sheet of retinal pigment which turns forward 
sharply lilie a spur at the pupillary margin, p. At one spot the posterior layer, ft, of the pig- 
ment has separated so that the anterior layer, w can be seen isolated. Close to the pupillary 
margin, the cross section, sp. of the sphincter pupillge is visible. From the posterior wall of 
Schlemm's canal rises the ciliary muscle, consisting of longitudinal fibers, M, and circular 
fibers, Mu : the transition from one portion to another is effected by the radial fibers, r. At 
the anterior margin of the circular portion is seen the cross section of the circulus anteriosus 
iridis major (a). Upon the ciliary muscle are situated the ciliary processes, P, which are cov- 
ered by the two layers of the pars ciliaris retinae— namely, by the pigmented cellular layer, pe, 
which is the continuation of the pigment epithelium, Pe, and by the non-pigmented layer, jyc, 
the continuation of the retina proper, R. The flat part of the ciliary body, the orbiciilus cili- 
aris, 0, extends to the ora serrata, o, where the chorioid, Cft, and the retina, P, begin. Upon 
the orbiculus lie the fibers of the zonule of Zinn, 2, which farther forward pass into the free 
portion, z,, of the zonula and there inclose the cavity of the canal of Petit, i. The lens, J^, 
shows at its equator, besides the attachments of the zonular fibers, the cross section, fc, of the 
ring of nuclei. 



256 



DISEASES OF THE EYE. 




Fig. 72. — Posterior Layers of 
THE Iris of an Albinotic Hu- 
man Eve. Magnified 350 x 1. 

a, branched cells of the iris stro- 
ma; b, posterior limiting mem- 
brane ; c, anterior, and rf, pos- 
terior, stratum of the retinal 
pigment layer. 



in normal eyes a faint tremulousness of the iris (iridodonesis), which otherwise 
occurs only in dislocation of the lens. This is due to the fact that with a con- 
tracted pupil the posterior chamber is deeper and at the same time the greatly 
dilated iris is considerably thinned — circumstances both of which favor waver- 
ing of the iris. 

The retinal pigment layer is composed of two strata of cells, the recognition 
of which, however, is rendered very difficult by their profuse pigmentation. 

The two strata can be clearly distinguished from 
each other only in the albinotic eye (Fig. 73) and 
in the embryo (and sometimes also in the new- 
born infant) ; we can then also establish the fact 
that they are the continuation of the two layers 
of the retina upon the posterior surface of the 
iris. The anterior stratum of pigment (c, Fig. 
73) arises from the pigment epithelium of the 
retina; the posterior {d) from the retina proper 
(Fig. 89). In the adult eye a separation not in- 
frequently takes place between the two strata, 
because they are not attached with the same de- 
gree of firmness to the iris. While the anterior 
stratum is very intimately adherent to the pos- 
terior surface of the iris, the posterior stratum readily becomes separated from 
it (in Fig. 71 the separation has resulted accidentally from the dissection). 
When adhesions of the posterior surface of the iris to the capsule of the lens 
(posterior synechias) are torn away the posterior stratum is left as a black coat- 
ing upon the anterior capsule, while the anterior stratum remains upon the iris. 
So, too, by penciling the iris we can easily remove the posterior stratum, leaving 
the anterior stratum behind upon the posterior surface of the iris. Then, when 
we make a microscopical examination of the iris that we have penciled, we find 
the anterior stratum intimately connected with the posterior limiting mem- 
brane. 

As is universally known, the color of the iris changes in the first years of 
life. Most children are born with a deep-blue iris. The stroma contains but 
little pigment and is still very thin, so that the posterior pigment layer is seen 
through it, having a bluish look. With increasing age the stroma becomes 
thicker and thicker. If, while this is taking place, the pigmentation does not 
increase, the iris simply becomes of a light blue or gray; but if, simultaneously, 
there is an increase of the pigment of the stroma, the iris takes on a brown color. 
The transformation of a blue iris into a brown one is sometimes confined to a 
part of the membrane, so that a brown sector is seen in an otherwise light- 
colored iris. Moreover, the iris of one eye may be blue and that of the other 
brown. The color of the iris is always proportioned to the pigmentation of the 
rest of the body. The dark races always have a dark iris. 



(5) Ciliary Body. 

57. The ciliary * body is brought into view when the eyeball is 
bisected, and the vitreous, the lens, and the retina are removed, so that 

* From cilia, lashes, because of the fine, radiating folds. The ciliary body is 
also called cyclon (hence oyolitis), from KixKos, a circle. 



ANATOMY AND PHYSIOLOGY OP THE UVEA. 257 

the uvea is everywhere exposed. The spot where the retina is torn 
away anteriorly is marked by a jagged line — the ora serrata (u, o, Fig. 
73). Corresponding to this there is a change in the coloration of the 
uvea, which behind this line is brown (chorioid), in front of it black 
(ciliary body). At the anterior margin of the black zone rise the 
ciliary processes, about seventy in number. These are conspicuous not 
only because they jut forward, but also because of their lighter color, 
their apices being less strongly pigmented than are the depressions 
between them. The anterior zone of the ciliary body, bearing the 
ciliary processes, is called the folded part of the ciliary body — corona 
ciliaris (c^. Fig. 73) ; back of this is the posterior part of the ciliary 
body — orbiculus ciliaris (or) — which is smooth and of a uniform black 
color. 

If we strip off the entire uvea from the cornea and sclera, we get a 
view of the outer side of the ciliary body. This is covered by a layer 
of gray tissue — the ciliary muscle. 

Longitudinal sections (i. e., those carried in a meridional direction, 
Fig. 71) are the ones best adapted for accurate study of the ciliary 
body. In such sections the ciliary body appears triangular. Its short- 
est side looks forward, and at about its center gives origin to the iris. 
The two long sides of the triangle look inward and outward respec- 
tively. The inner side bears the ciliary processes {P, Fig. 71), while 
the outer side is formed by the ciliary muscle (M). 

Microscopical Anatomy. — If we examine the separate layers of the 
ciliary body, proceeding from without inward, we first come upon the 
ciliary muscle. This was discovered by Briicke, and was called by him 
the tensor chorioideee. It consists of two portions, distinguished by 
the differing direction of their muscular fibers, (a) The external por- 
tion contains the longitudinal or meridional fibers — that is, those run- 
ning from before backward {M, Fig. 71). As these are the ones first 
discovered by Briicke, they are also called Briicke's portion. The longi- 
tudinal fibers arise from the external fibrous tunic of the eye, at the 
boundary between the cornea and sclera (at I), and run straight back- 
ward to a point at which they gradually are lost in the external layers of 
the chorioid (Oh), (b) The second portion of the ciliary muscle lies to 
the inner side of the first, and contains those fibers which have a cir- 
cular course, and which, hence, in sections made meridionally, are seen 
in cross section (JJu, Fig. 71). They are designated as Miiller's portion, 
from their discoverer, Heinrich Miiller. 

The ciliary processes {P, Fig. 71) are placed upon the ciliary mus- 
cle. They consist of a connective-tissue stroma, which, along with 
branched pigment cells, contains an extraordinary number of blood- 
vessels, so that the ciliary processes must be regarded as the most vascu- 
lar portion of the entire eyeball. The inner surface of the ciliary body 
is covered by three layers of tissue. The first of these is a homogeneous 
17 



naeal 




a' 
on 






258 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 259 

membrane, the hyaline lamella of the ciliary body. Succeeding this is 
a layer of pigmented cells, the pigment epithelium {P, Figs. 74 and 
75) ; and, lastly, a single stratum of non-pigmented, cylindrical cells 
{0} forming the most superficial layer— i. e., the one that adjoins the 
vitreous humor. The last two layers are the continuation of the retina, 
which here has ' become reduced to a double row of cells i. e., a pig- 
mented and .non-pigmented row. They are hence called the pars 
ciliaris retinm. All three layers pass over upon the posterior surface 
of the iris, the deepest layer, or hyaline membrane, being continued 
into the posterior limiting membrane of the iris, while the layers of pig- 
mented and non-pigmented cells are converted into the two strata of the 
retinal pigment layer of the iris (pars iridica retinas, c and d, Fig. 73). 

The place where the iris and the ciliary body are attached to the 
sclera deserves particular attention. We can readily convince ourselves 
that the iris does not arise from the sclero-corneal junction, but farther 
back, so that the most anterior portion of the sclera is still in the con- 
fines of the anterior chamber. The connection between the sclera and 
the root of the iris is made by means of loose tissue which arises at the 
margin of the cornea, and from this point extends backward to the 
root of the iris (Fig. 71, 1). This tissue, which is called the Ugafnentum 
pectinatum, fills up the angle between the iris and the corneo-sclera, 
so that this angle is rounded oif into a sinus — the sinus of the anterior 
chamber. Histologically, the tissue of the ligamentum pectinatum is 
composed of superimposed, laminated lamellae, which start from the 
margin of Descemet's membrane and run backward to a point at 
which a part of the longitudinal fibers of the ciliary muscle abuts 
against them. These lamellee consist of trabeculse inclosing rounded 
alveoli, so as to form, when superimposed, a spongy tissue (Fig. 76). 
Directly to the outer side of them, just at the boundary between the 
cornea and sclera, is observed an open space (Fig. 71, s), representing 
Schlemm's canal (sinus venosus sclerse), the inner wall of which is 
thus formed by the ligamentum pectinatum. 

The iris and ciliary body take part in the formation of the two 
chambers of the eye. The anterior chainler is bounded in front by the 

Explanation op Fig. 73. — The nasal wall of the orbit is formed by the lamina papyracea 
(OS planum) of the ethmoid, L, the lachrymal bone, T, and the frontal process, F, of the su- 
perior maxilla. The last two bones bound the fossa sacci lacrimalis, in which lies the lachry- 
mal sac, S. The bony walls of the orbit are coated by a periosteum (periorbita), P, from which 
the palpebral ligaments take their origin. The internal palpebral ligament, I, divides into an 
anterior limb, v, and a posterior limb, A, which together inclose the lachrymal sac. From the 
posterior limb arise the fibers of Horner's muscle, H. Ze, external palpebral ligament ; fi and 
fe, the slips of fascia, likewise passing from tlie periosteum to the internal rectus muscle, J, 
and the external rectus, B. The skin, N, of the dorsum of the nose passes into the lower lid. at 
whose free border are seen the cilia and the orifices of the Meibomian glands, m ; between the 
two extends a gray line, i. At the inner extremity of the lid lies the inferior punotum lacri- 
male, p, and farther along in the conjunctival sac the caruncle, c, and the plica semilunaris, n. 
From the eyeball, the lower half of which is exhibited, the lens and along with it the vitreous 
humor have been taken out, and the pigment epithelium has been removed by penciling. The 
anterior chamber, fc, the iris, ir, and the ciliary body, consisting of the corona ciliaris, Cj, and 
the orbiculus ciliaris, or, are visible. Back of the ora serrata, o, is the chorioid with its veins 
which are aggregated into vortices, v. f, fovea centralis retinae ; c^, central vessels of the 
optic nerve, O, entering it at e. 



260 



DISEASES OF THE EYE. 



cornea, behind by the iris and in the region of the pupil by the an- 
terior capsule of the lens, and at its margins by the tissue of the liga- 
mentum pectinatum, beneath which lie Schlemm's canal and the an- 
terior border of the ciliary body. Even under normal conditions the 



P c z 



F c 





Fig. 74. 



Fig. 75. 



Fig. 74. — Portion op a Meridional Section throdgh a Ciliary Process, somewhat behind 
ITS Apex. Magnified 240 x 1.— The stroma of the ciliary process, S, con.sists of delicate con- 
nective tissue in which lie the broad and very thin-walled blood-vessels, g. Succeeding these 
are the two layers of the pars ciliaris retinae. One is the pigment layer, P, representing the 
continuation of the pigment epithelium ; its cells, on account of their deep pigmentation, dis- 
close peither their nucleus nor their contour, and they also conceal (as too they do in Fig. 75) 
the hyaline lamella, which can be rendered visible only by penciling these cells out. The 
second layer, C, which is uupigmented, consists of a single layer of cubical cells, represent- 
ing the continuation of the retina proper. 

Fig. 75. — Superficial Layers op the Flat Portion ^Orbiculus Ciliaris) of the Ciliary 
Body in Meridional Section. Magnified 270 x 1.— Taken from the same section as Fig. 74. 
The cells of the pigmented layer, P, of the ciliary body dip into the stroma, 5, of the latter 
in the form of processes which are club-shaped or gland-shaped (but contain no gland cav- 
ity). The cells of the superficial non-pigmented layer, C, are here longer than in Fig. 74 and 
cylindrical. On their tree surface lie the fibers of the zonule of Zinn. 



depth of the anterior chamber is variable. It is greatest in the eyes of 
the young, and diminishes with advancing age. Myopic eyes have a 
deep anterior chamber, hyperopic eyes a shallow one. Even in the 
same eye the depth of the anterior chamber varies, as it becomes shal- 
lower during the accommodative act from the protrusion of the anterior 
surface of the lens. Th& posterior chamber is produced by the iris not 
being in contact with the capsule of the lens by its whole posterior 
surface, but only by its pupillary margin. Thus an open space is left 
between the iris and the lens, which increases in depth from the pupil- 
lary to the ciliary margin of the iris, and hence in cross-section has a 
triangular shape. This space, the posterior chamber of the eye, is 
bounded in front by the iris and \o the outer side by the ciliary body, 
while its inner and posterior wall is formed by the lens {L, Fig. 71) 
and the zonule of Zinn (21, Fig. 71), the latter bridging over the inter- 
space between the lens and the ciliary body. The two chambers com- 
municate only by means of the pupil. 

The ciliary muscle is composed of smooth muscular fibers, which do not 
present a compact mass but are disposed in flat bundles, which are separated 
by connective tissue, and which interlace repeatedly so as to form a sort of 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 



261 



plexus. For this reason there is no well-marked separation between the two 
portions of the ciliary muscle ; on the contrary, the longitudinal fibers by a very 
gradual transformation become bent so as to take a circular direction. Those 
bundles which effect the transition from fibers of one direction to those of 
another have been denoted by the name of radial bundles (r. Fig. 71). Like 
the longitudinal fibers they arise fr^m the wall of Schlemm's canal, but, unlike 
them, they do not extend outward and backward, but directly backward, and 
pass into the circular fibers. 

The proportion between longitudinal and circular fibers varies according to 
the refractive state of the eye. In hypermetropic eyes the circular fibers are 
strongly developed, while in myopic eyes they are present in much smaller num- 
bers (see § 144, and Figs. 233, 224, and 225). 

The region of the angle (or sinus) of the anterior chamber demands particular 
consideration, both because of its complicated anatomical relations and also 
because of its importance with regard to the metabolic processes and the dis- 
eases of the eye. This region was studied in the eyes of animals before it was 
in human eyes, and hence names were selected at that time which are still in 
vogue, although they are not appropriate for the human eye. Thus Hueck in- 
troduced the name ligamentum pectinatum, because he found in the eyes of the 
Ungulata that, upon stripping the iris from the sclera, the tissue that united 
these parts projects in a series of ridges resembling the teeth of a comb. The 
triangular space between the sclera and the root of the iris which is filled by 




Fig. 76.— Ligamentdm PECTiNATrm (Sorface View). Magnified 700 x 1, 

TrabeculBB, which show a delicately fibrillar structure, inclose alveoli, the larger of which are 
eUiptical, and directed so that their long axis lies parallel to the margin of the cornea^ Upon 
the walls of these alveoli lie cells (endothelial cells) provided with nucleus and large proto- 
plasmic cell body ; small alveoli are sometimes entirely filled by such cells. 

the ligamentum pectinatum is also called Fontana's space, because Fontana was 
the first to describe the rather large cavities which are found in many animals 
between the lamellae of the ligamentum pectinatum. 

The ligi/mentmnpectiiiiitum is covered by the endothelial layer which passes 
over it from the posterior surface of Descemet's membrane to the anterior sur- 
face of the iris. Through the gaps in the lamellae of the ligamentum pectina- 



262 DISEASES OP THE EYE. 

turn the endothelium passes from the surface of the ligament into the deeper 
parts of it, and supplies all the lamellse and trabeculse of this spongy tissue 
with an endothelial lining (Fig. 76). 

When the iris and the ciliary body are stripped o£E from the corneo-sclera, 
the ligamentum pectinatum comes away with them. It thus shows the close 
interrelation between it and the uvea, a relation, moreover, that is also proved 
by embryology, according to which both the ligamentum pectinatum and its 
derivative, Descemet's membrane, belong to the uvea. Hence, embryologically 
speaking, the uvea forms a perfectly closed hollow sphere, consisting of the 
chorioid, ciliary body, iris, ligamentum pectinatum, and Descemet's membrane. 

By stripping off the uvea, together with the ligamentum pectinatum, from 
the corneo-sclera, an opening is made into Sehhmm's canal, the inner wall of 
which is formed by the ligamentum pectinatum. It is then visible as an open 
channel running along the boundary between the cornea and sclera — scleral 
channel. Besides this, the ligamentum pectinatum covers in a part of the an- 
terior surface of the ciliary body, which therefore, within these limits, likewise 
belongs to the region of the anterior chamber. Hence inflammatory products, 
and especially pus, may pass from the ciliary body directly into the anterior 
chamber, traversing the tissue of the ligamentum pectinatum as they do so. 
Kew growths also sometimes take this path, starting from the ciliary body and 
growing forward into the anterior chamber in the region of its sinus (Fig. 105). 

It was a good while before people got a correct idea of the anatomical rela- 
tions existing in the region of the anterior and posterior chamber, and even at 
the present time we very frequently find drawings which represent these rela- 
tions incorrectly. The existence of the posterior chamber was for a long time 
contested, it being supposed that the iris came into contact with the lens by its 
whole posterior surface. If this were the case, the anterior chamber would 
present quite a different shape, since it would have to be much deeper at its 
periphery than it is. This state of things is actually observed in those patho- 
logical cases in which the iris is adherent throughout by means of an exudate 
to the capsule of the lens. The iris is then found to be retracted at its periph- 
ery much more than usual (see Fig. 98). The existence of a posterior cham- 
ber in the normal eye can be demonstrated by freezing a recently extracted eye : 
upon opening it, we see a ring-shaped piece of ice (the frozen liquid of the pos- 
terior chamber) lying between iris and lens. 

(c) Chorioid. 

58. The chorioid * is that part of the uvea which lines the posterior 
section of the eye from the ora serrata to the aperture for the optic 
nerve. If we observe it in situ, after opening the eyeball and removing 
the vitreous together with the retina, its inner surface appears smooth 
and uniformly brown. Then, if we try to strip it ofE from the sclera, 
we notice that at several spots it is attached more firmly than at others. 
The most intimate connection is at the margin of the aperture for the 

* From xopioEiS^j— i. e., like the x^P^o" (= Lat., corium). This latter word sig- 
nifies " skin," and not merely the epidermis, but also the envelope (chorion) of the 
embryo in utero ; and, in fact, it is the latter that the chorioid resembles, from its 
abundant supply of vessels. This word is also erroneously written choroid or 
choroid. 



ANATOMY AND PHYSIOLOGY OF THE UVEA, 263 

optic nerve ; in addition, loose attachments exist in the places where 
vessels and nerves enter the chorioid from the sclera, and especially in 
the region of the posterior pole (region of the posterior ciliary arteries) 
and of the equator (venae vorticosa). When, after tearing away these 
connections, we have separated the chorioid from the sclera, we get a 
view of the outer surface of the chorioid, which has a shaggy appear- 
ance on account of the shreds of membrane adhering to it. 

Microscopical Anatomy.— The chorioid consists of five layers, which 
succeed one another in the following order, proceeding from without 
inward : 

1. The suprachorioid (s. Fig. 77) consists of numerous fine non- 
vascular but richly pigmented lamella3 lying between the chorioid 
proper and the sclera {sc). Upon stripping these latter apart these 




FiQ. 77.— Cross Section through the Chorioid. Magnified 175 x 1. 

The chorioid consists of the suprachorioid, s, the layer of large vessels, H, the layer of medium- 
sized vessels, S, the ehorio-capillaris, i?, and the lamina vitrea, G. In the layer of large 
vessels are recognizable arteries, A. veins, F, and pigment cells, p. The inner surface of 
the chorioid is covered by the pigment epithelium, P, its outer surface by the sclera, ac. 



lamellffi are torn in two, and are left hanging partly upon the inner 
surface of the sclera, partly upon the outer surface of the chorioid, 
which thus acquires the rough, shaggy aspect above mentioned. 

2. The layer of large vessels (Haller) {H, Fig. 77). These are 
chiefly veins, which are placed very close to each other and anastomose 
repeatedly. The intervals between the vessels (intervascular spaces) are 
richly supplied with pigment cells {p), and are hence of a brown color 
This layer, accordingly, gives the same appearance upon a surface view 
as if we were looking at a plexus of bright lines (the vessels) upon a 
dark ground (Fig. 73). This is a picture which we often have the 
opportunity of seeing with the ophthalmoscope in the living eye (tes- 
sellated fundus, see Figs. 10 and 143). 



264 



DISEASES OF THE EYE. 




Fig. 78. — Pigment Cells of the Stroma of the 
Chorioid. Magnified 400 x 1. 

They are branched, anastomosing, connective- 
tissue cells, with numerous pigment granules 
and an unpigmented nucleus. 



3. The layer of medium-sized vessels (Sattler) (Fig. 77, *S'), which 
is very thin and but slightly pigmented. 

4. The layer of capillaries {chorio- capillar is, or membrana Euyschii 
—although it was not discovered by Eaysch— .ff, Fig. 77). This con- 
sists almost exclusively of capil- 
laries which have a very wide 
bore, and at the same time are so 
closely packed together that the 
interspaces between the capilla- 
ries are often narrower than the 
capillaries themselves. This lay- 
er contains no pigment. 

5. The lamina vitrea {or lam- 
ina iasalis G, Fig. 77), a homo- 
geneous membrane coating the 
inner surface of the chorioid. 

We may briefly summarize 
the structure of the chorioid in 
the following way : The chorioid 
consists mainly of vessels which 
are arranged according to their caliber in three superimposed layers, 
in such a way that the largest vessels lie farthest to the outside, the 
smallest vessels farthest to the inside. The purpose of this arrange- 
ment is easily comprehended, since the chorioid is in great part de- 
signed for the nourishment of the tissues lying to the inner side of it 
(retina and vitreous). Hence the minutest vessels, the capillaries, from 
which the nutrient plasma of the blood exudes, must lie upon the 
inner surface of the chorioid. The vascular part of the chorioid is 
covered on either side by a non-vascular layer — 
i. e., on the outside by the suprachorioid, on the 
inside by the lamina vitrea. All the layers of the 
chorioid, with the exception of the two inneririost 
ones — the capillary layer and the lamina vitrea — 
contain pigment inclosed in branched pigment 
cells (Fig. 78). To its abundant supply of pig- 
ment the chorioid owes its dark-brown color. 
The inner surface of the chorioid is covered by 
the pigment epithelium (P, Fig. 77) which lies 
upon the lamina vitrea. This, too, was formerly 
reckoned in with the chorioid, because it remains attached to it after 
the retina has been stripped off; embryological researches, however, 
have shown that it really belongs to the retina. It consists of regularly 
hexagonal cells, each of which, has an unpigmented nucleus, while the 
protoplasm contains an abundance of pigment granules (Fig. 79). 
From this the entire layer acquires a dark -brown color. 




Fig. 79.— Pigmented Epi- 
thelial Cells of the 
Retina. Magnified 500 
X 1. 

They are hexagonal epi- 
thelial cells, with pig- 
ment granules and an 
unpigmented nucleus. 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 265 

The uvea in all of its parts is very rich in nerves. The ciliary 
nerves get to the uvea by piercing the sclera near its posterior pole. 
They form in the chorioid, and particularly in the ciliary muscle, a 
dense plexus, in which numerous ganglion cells are intercalated. The 
iris is also very rich in nerves, but contains no ganglion cells. The 
■ iris and the ciliary body contain, in addition to the motor nerves de- 
signed for the ciliary muscle and the muscular apparatus of the iris, a 
very great number of sensory nerve fibers which arise from the tri- 
geminus ; hence, inflammation of these parts is frequently attended 
with great pain. The chorioid, on the contrary, seems to possess no 
sensory nerves, since inflammation of this membrane runs its course 
without producing any sensations of pain. 

The chorioid is continuous with the flat part of the ciliary body (orbiculus 
ciliaris), which possesses essentially the same structure as the chorioid, and is 
distinguished from it only by a somewhat different arrangement of the blood- 
vessels, and also by the absence of the chorio-capillaris, which ends at the ora 
serrata. The difference in color between the brown chorioid and the black or- 
biculus (Pig. 73), so striking to the naked eye, is not referable to a difference in 
the pigmentation of these parts of the uvea, but to a difference in the pigment 
epithelium which covers them and which belongs to the retina. 

All the pigment that is contained in such abundance in the interior of the 
eye belongs to two categories: 1. In the tissue of the uvea itself there are 
everywhere found branched cells, of the character of the connective-tissue cells, 
containing pigment (Fig. 78). These are the pigment cells of the stroma, and 
the pigment contained in them is called stroma pigment, or, because it lies in 
the uvea itself, uveal pigment. 2. The inner surface of the uvea is everywhere 
coated with a layer of pigmented cells, belonging to the retina and having the 
character of epithelial cells {pigment epithelium, Fig. 79). This pigment, which 
hence lies not in the uvea but to the inner side of it, is called the retinal pig- 
ment. 

These two kinds of pigment are further distinguished by their minute 
structure. The pigment in the stroma cells of the uvea consists of small amor- 
phous masses ; but the pigment granules in the cells of the pigment epithelium 
are short, rod-shaped structures, which should probably be regarded as small 
crystals, such as occur, very distinctly marked, in some of the lower vertebrates. 

The pigmentiferous cells, including both those of the stroma and those of 
the pigment epithelium, are similar in all eyes, but the amount of pigment 
which they contain varies greatly. To this fact is due the inequality in the 
pigmentation of eyes; if the cells contain no pigment whatever, the eye is 
albinotic (Pig. 73). 

II. Circulation and Metabolism of the Uvea. 
(a) Blood-vessels. 
59. Three systems of blood-vessels exist in the eye— that of the con- 
junctiva, that of the retina, and that of the uvea (ciliary system of ves- 
sels). The arteries of the ciliary system are : 1. The posterior ciliary 
arteries. These arise from the ophthalmic artery, and enter the in- 



266 DISEASES OP THE EYE. 

terior of the eye through the sclera in the region of the posterior pole. 
The majority of them pass at once into the chorioid (short posterior 
ciliary arteries, c, c, Pig. 80). Two of them, however (the long pos- 
terior ciliary arteries, d. Fig. 80), run, one on the outer side, the other on 
the inner side, between chorioid and sclera as far forward as the ciliary 
muscle. Here each divides into two branches, which run in a direction 
concentric with the margin of the cornea, and unite with the branches 
of the artery of the opposite side to form an arterial circle, the circulus 
arteriosus iridis major (Fig. 80, h, and Fig. 71, a). This gives off the 
arteries for the iris, which extend radially from its ciliary to its pupil- 
lary margin (Fig. 80, i). Shortly before they reach the latter they form 
by anastomoses a second, smaller vascular circle, the circulus arteriosus 
iridis minor or the small circle of the iris (Fig. 80, k). 2. The anterior 
ciliary arteries come from in front, arising from the arteries of the four 
recti muscles (Fig. 80, e). They perforate the sclera near the margin of 
the cornea and assist in forming the circulus arteriosus iridis major. 
The short posterior ciliary arteries are therefore designed mainly for 
the chorioid, the long posterior ciliary arteries and the anterior ciliary 
arteries for the ciliary body and the iris. 

The arrangement of the veins is essentially different from that of 
the arteries. In the chorioid the capillary network of the chorio-capil- 
laris (Fig. 80, /) is fed by the arteries. The blood from this flows off 
through a very great number of veins that keep uniting to form larger 
and larger trunks. A number of these trunks simultaneously con- 
verge to a common center, where, consequently, a sort of whorl or vortex 
is produced by veins coming together from all sides. Fig. 73 shows a 
surface view of two such vortices, v. These vortices, the number of 
which amounts to four at least, usually more, lie somewhat behind the 
equator of the eye ; from them are given off the venae vorticosse, which, 
perforating the sclera in a very oblique direction, carry off the blood to 
the outside (Fig. 80, I). 

In the ciliary processes the arteries break up into a great number 
of twigs, which pass over into thin- walled veins (g, Fig. 80). These 
constitute the greater part of the ciliary processes, which, accordingly, 
consist mainly of vessels. The larger veins which are formed by the 
union of these vessels, and also most of the veins of the ciliary muscle, 
pass backward to the vense vorticosse. The veins that come from the 
iris (it, Fig. 80) likewise pass to the venae vorticosse. Hence almost all 
the venous blood of the uvea empties into the latter. A portion of the 
veins coming from the ciliary muscle (m. Fig. 80), however, take an- 
other course, as they pass out directly through the sclera and thus come 
into view beneath the conjunctiva, near the margin of the cornea (an- 
terior ciliary veins. Fig. 80, e^). In their course these correspond to 
the anterior ciliary arteries ; it is they that principally constitute the 
violet vessels which we see running backward beneath the conjunctiva 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 



267 



in ciliary injection or in stasis within the eyeball (glaucoma). The 
anterior ciliary veins anastomose with the conjunctival veins, and also 



Fig. 




Blood-vessels of the Eye. (Schematic.) (After Leber.) 



The retinal system of vessels is derived from the central artery, a, and the central vein, a,, ( 
the optic nerve, which give off the retinal arteries, 6, and the retinal veins, 6,. inese ena i 
the ora serrata. Or. 



The system of ciliary vessels is fed by the posterior short ciliary arteries, cc "f^^ POf'^rior long 
ciliary arteries, I and the anterior ciliary arteries, e. From these ^"f ^J"® ZfJ^^^Jfriosus 
work of the chorioidal capillaries, /, and of the ciliary body, g, and the «™3„^,,^7?['°™f 
!^Ai„ „=^„, I, Tiv^Tv, tv,io io=f. onrino- the art.eries of the ins. I. which at the smaller Linnerj 



circumrerence ot ine laraer lorm tiie unuuiuo ""■"=',', ^V" * .v,„„;n.ii ^nrticnssp I- those 
iris, .•„ of the ciliary body, and of the chorioid are collected into the venae ™rticosa; i , tnose 
veiis, however, that come from the ciliary muscle (m) leave the eye as anterior cmd,ry 
veins, e,. With the latter, Schlemm's canal, n. forms anastomoses. 
The system 'of conjunctival vessels consists of the posterior coo5"°<=t'^tw!f !,f • "to meet' them- 
communieate with those branches of the anterior ciliary ™sf>s which ran to meet tne^^^ 
that is, with the anterior conjunctival vessels, p-and form ^>tb t ?nfrt' nr retSa • i lens • 
the cornea, o. O, optic nerve ; S, its sheath ; Sc, sclera ; A, chorioid , N, retma , i., lens , 
H, cornea ; B, internal rectus ; B, conjunctiva. 



268 



DISEASES OP THE BYE. 




with Schlemm's canal. The latter is a venous sinus running along the 
sclero-corneal Junction (Pig. 80, n; Fig. 71, s). 

The blood-vessels of the eye belong for the most part to the region of the 
uvea. It is this fact which determines the part played by the latter; for, 
while the firm corneo-sclera serves for the protection of the eye exteriorly 
and the retina for the perception of light, to the uvea is allotted the task 

of providing for the nourishment of the eyeball. 
Such is the abundance of blood-vessels which it 
contains that it really consists mainly of them; 
and by this fact its great tendency to become in- 
flamed is accounted for. 

The separate branches of the ciliary system of 
vessels anastomose repeatedly with each other — 
a circumstance which favors the compensation 
of circulatory disturbance. Thus, for instance, 
in glaucoma, in which the outflow of venous 
blood through the vense vorticosse is impeded, 
we see the anterior ciliary veins taking their 
place and carrying o3 larger quantities of blood 
than usual. 

The ciliary vessels likewise supply the sclera 
with blood, giving oflE a few minute twigs to it 
as they pass through it. The number of blood- 
vessels in the sclera, ^however, is very small. 
Nevertheless, in the immediate neighborhood of 
the entrance of the optic nerve, from two to 
four branches of the short posterior ciliary arteries enter the sclera and form 
in it by anastomoses an arterial ring, Zinii's scleral circle of vessels, surround- 
ing the foramen for the optic nerve. This is of importance for the nutrition 
of the optic nerve, because numerous little branches go from it to the optic 
nerve and its sheaths, and anastomose with the branches of the central artery 
of the nerve. It is here, then, that the only connection between the ciliary 
and the retinal system of vessels exists. 

It not infrequently happens that individual branches arising from the scleral 
circle of Zinn, instead of remaining in the optic nerve, make a bend and leave 
the nerve. They then enter the retina and run in it toward the macula lutea. 
These vessels, which are called cilio-retinal, ordinarily supply with blood a 
small district of the retina lying between the papilla and macula (Fig. 81). 



Fig. 81. — Cilio-rbtinal Artery. 

From the outer and lower mar- 
gin of the papilla rises a cilio- 
retinal artery (a), making a 
hook- like bend. In this case 
it is larger than usual because 
it is destined to replace the 
main infero-external branch 
(inferior temporal branch) of 
the central artery, which 
branch is wanting. 



{b) Lymph Passages. 

60. If we disregard the conjunctiva, thei-e are no lymphatic ves- 
sels in the eye. They are replaced by lymph channels and lymph 
spaces. We distinguish the lymph passages into anterior and pos- 
terior. 

1. Anterior Lymph Passages. — The lymph of the anterior section 
of the eye is collected into two large lymph spaces — namely, the auT 
terior and the posterior chambers — which communicate by means of 
the pupil. The outflow of lymph from these spaces takes place by its 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 



269 



discharge from the posterior chamber through the pupil into the an- 
terior chamber ; thence it filters through the mesh work of the liga- 
mentum pectinatum into the subjacent Schlemm's canal (Fig. 82, S), 
and from there gets into the anterior ciliary veins (e) with which 
Schlemm's canal is in direct communication. 

3. Posterior Lymph Passages.— These are a,sM\ows: (.J) The hya- 
loid canal, or central canal of the vitreous (Fig. 82, A), which extends 
from the point of entrance of the optic nerve forward as far as the 
posterior pole of the lens. During the development of the eye this 




—Lymph Passages of the Eye. (Schematic.) 



S, Sciilemm's canal ; c, anterior ciliary veins ; h, hyaloid canal ; p, perichorioidal space, which 
communicates by means of the venas vorticosae, v, with Tenon's space, t,t;s, supravaginal 
space ; ;', intervaginal space ; e ej, continuation of Tenon's capsule upon the tendons of the 
ocular muscles (lateral invagination). 



canal lodges the hyaloid artery, which in the fully formed eye disap- 
pears, while the canal remains. It has its outlet in the lymph spaces 
of the optic nerve. (B) The perichorioi(3al space (p, Fig. 82) is the 
space between the chorioid and sclera. It is continued along the ves- 
sels which pass through the sclera, especially the venae vortieosffi (v), 
and thus communicates with (C) Tenon's space (Fig. 82, t, t), which 
lies between the sclera and Tenon's capsule. The outflow of lymph 
from all these spaces takes place into the lymph passages, which spread 



2T0 DISEASES OP THE EYE. 

out along the optic nerve. These latter are {D) the intervaginal space, 
which is found between the sheaths of the optic nerve {i. Fig. 82), and 
{E) the supravaginal space {s, Fig. 82), which surrounds the sheaths 
of the optic nerve. 

By far the greatest amount of lymph leaves the eye through the 
anterior lymph passages. These, therefore, are the more important ; 
their impermeability leads to serious changes in the eye (glaucoma), 
while up to the present time nothing certain is known in regard to 
disturbances of the function of the posterior lymph passages. 

We owe our knowledge concerning the lymph passages chiefly to Schwalbe. 
For their study we make use of injections into the tissue of the dead and also 
of the living eye. Thus we find in what directions fluids penetrate most readily 
in and between the tissues of the eye. But to justify us in regarding the spaces 
thus exhibited as lymph passages, proof must also be brought to show that they 
are coated by a continuous layer of endothelium ; and this, too, Schwalbe has 
established in the lymph spaces which he discovered. 

(c) Nutrition of the Eye. 

61. The secretion of the fluids of the eye, and also the nourishment 
of its tissues, take place mainly through the vessels of the uvea. 

The aqueous humor is a limpid liquid, which in the normal state 
contains only an excessively small amount of albumin. It is produced 
by the iris and the ciliary processes, the latter playing the more im- 
portant part in the process ; for, in cases of congenital or acquired defi- 
ciency of the iris, the aqueous is still secreted in normal amount. The 
aqueous secreted by the ciliary processes arrives first into the posterior 
chamber, from which it passes through the pupil into the anterior 
chamber. Here it again leaves the eye by way of the ligamentum pec- 
tinatum and Schlemm's canal. The secretion of aqueous goes on much 
more rapidly when the latter has been evacuated — e. g., by puncture of 
the cornea — than it does under physiological conditions. In the for- 
mer case the anterior chamber is restored as early as a few minutes 
after it has been evacuated, a thing we have frequent opportunity of 
observing during operations. The rapid reproduction of aqueous is 
favored by the fact that after its escape the ocular tension is reduced 
much below the normal. Hence the blood pours in greater quantity 
into the vessels of the iris and ciliary body, thus relieved of their ex- 
ternal pressure, and these expand proportionally and allow fluid to 
transude from them in greater abundance. This fluid that accumu- 
lates in the anterior chamber after the evacuation of the aqueous is 
distinguished from normal aqueous by the considerable amount of al- 
bumin that it contains. 

The cornea is nourished mainly by the network of marginal loops 
of the limbus, and to a small extent also by the aqueous humor which 



ANATOMY AND PHYSIOLOGY OP THE UVEA. 271 

makes its way into it by diffusion. The other two non-vascular tissues 
of the eye, the lens and the vitreous, are entirely dependent upon the 
uvea for their nourishment. They obtain nutrient material mainly 
from the ciliary body, perhaps also from the anterior section of the 
chorioid. Hence in diseases of these parts we very frequently see 
cloudiness of the lens and cloudiness and liquefaction of the vitreous, 
making their appearance as an expression of the disturbance in the 
nutrition. The process of tissue metamorphosis in the lens appears to 
be very slow, since pathological changes in it (opacities) often either 
remain stationary for an exceedingly long time or extend but slowly. 
The retina has its own vessels, which, however, are situated simply in 
its inner layers and do not sufiSce for its nourishment. The retina, 
therefore, especially in its outer layers, is dependent upon the chorioid, 
whose chorio-capillaris indeed is almost directly adjoining. The chorio- 
capillaris, furthermore, must be credited with accomplishing the con- 
tinual regeneration of the used-up visual purple. 

The aqueous can not be regarded as simply lymph, since it is distinguished 
from the latter by containing extremely little albumin. It must rather be 
looked upon as a secretion, in whose formation the two layers of retinal cells 
(pigmented and non-pigmented) that cover the surface of the ciliary body, play 
the part of a secreting epithelium. Treacher Collins has called attention to the 
numerous glandlike processes that the pigment epithelium in the flat portion 
of the ciliary body gives off (Pig. 75), and ascribes the secretion of the aqueous 
mainly to them. 

The liquid that accumulates very rapidly in the anterior chamber after the 
aqueous has been withdrawn from it, and which is much more albuminous than 
the normal aqueous, is formed for the most part by direct transudation from 
the distended vessels of the ciliary processes, which transudation gives rise to 
numerous blisterlike elevations in the layer of retinal cells lining the ciliary 
processes (Greeff). 

With regard to the nourishment of the lens, it is assumed that nutrient 
material starting from the ciliary body and the anterior part of the chorioid 
enters it in the region of its equator. Inside of the lens the fluid circulates 
probably in clefts which lie between the fibers of the lens in the anterior and 
posterior cortical layers (Schlosser), and which under pathological conditions 
may become visible as stellate opacities. The lymph leaves the lens probably 
through the anterior capsule and empties into the anterior chamber (Samel- 
sohn). 

As regards the retina, various facts indicate that it is likewise dependent in 
part for its nourishment upon the chorioid, and particularly upon the most an- 
terior layer of the latter — i. e., the chorio-capillaris. This layer extends for- 
ward only as far as the retina itself, or at least the complicated structure of it, 
does— that is, as far as the ora serrata. Again, at that spot where the retina 
displays its functions most actively — i. e., in the region of the macula lutea — the 
capillary loops of the chorioid are most densely disposed ; and, lastly, there are 
many animals in which the retina has no vessels whatever, and hence evidently 
can be nourished only by the chorioid. The outflow of lymph from the retina 
takes place through the lymph sheaths surrounding the retinal vessels. 



272 - DISEASES OP THE EYE. 

(d) Intra-ocular Pressure. 

62. For the purpose of simplifying the study of the conditions of 
pressure, we may leave the lens out of consideration, and think of the 
eyeball as a capsule filled with fluid. The capsule is the fibrous cor- 
neo-sclera, which has only a very small degree of elasticity. The fluid 
contained in the capsule exerts upon the inner surface of the latter a 
pressure which, in accordance with the laws of hydrostatics, is trans- 
mitted with the same intensity in every direction, and hence presses 
with the same weight upon every unit of surface of the wall. A square 
millimetre of the posterior surface of the cornea has therefore the 
same pressure to bear as a square millimetre of any portion of the 
sclera. 

The intensity of intra-ocular pressure depends upon the relation 
between the capacity of the capsule and the amount of its contents. 
If the former becomes smaller or the latter greater, the pressure rises, 
and vice versa. Under physiological conditions, the capacity of the 
capsule — i. e., the volume comprised by the cornea and sclera — under- 
goes such inconsiderable variation that it may be neglected, and the 
capacity regarded as constant. The variations in intra-ocular pressure 
are hence referable to changes in the amount of matter contained in 
the eyeball, which may be increased or diminished. For example, the 
pressure at once sinks considerably when the aqueous has been evacu- 
ated by puncture of the cornea. 

Those portions of the contents of the eyeball whose amount is vari- 
able are the aqueous, the vitreous, and most of all the blood that circu- 
lates in the vessels of the inner tunics of the eye. Every increase or 
decrease of blood pressure in these vessels must result in a correspond- 
ing change in the ocular tension. Other causes, too, such as changes 
in the form and volume of the iris and ciliary muscle, the pressure of 
the lids and of the exterior muscles of the eye upon the ball, etc., can 
alter it. One might therefore be inclined to believe that it was subject 
to considerable variations. But, on the contrary, observation teaches 
us that the intra-ocular pressure under normal conditions is pretty co7i- 
stant. In fact, a regulation of the tension is effected by the circum- 
stance that the outflow of the fluid of the eye through the lymph 
channels (excretion) changes in such a way that variations of pressure 
are at once compensated for. For example, the pressure in the whole 
vascular system, and consequently in the eye as well, may be elevated 
as the result of great muscular effort. The intra-ocular pressure is 
thus heightened ; but proportionately more of the intra-ocular fluids 
which are subjected to this increased pressure are forced out of the 
eye through the excretory channels, so that the pressure very soon sinks 
again to its normal level. The converse would occur in a case in which 
the pressure has been diminished (e. g., in consequence of an escape of 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 273 

the aqueous humor) ; theu more blood flows into the vessels of the uvea, 
now subjected to less pressi;ire, and a more copious outflow of fluids into 
the interior of the eye (secretion) is the result. But at the same time 
the outflow of ocular fluids through the lymph channels (excretion) is 
diminished, because the pressure to which the ocular fluids are sub- 
jected is less. In this way the normal pressure is very soon restored. 

The practical estimation of the intra-ocular pressure is performed 
by palpating the eyeball through the closed lids, just as if we were in- 
tending to test for fluctuation. We determine in this way the degree 
of tension of the eye. This, to be sure, is not identical with the intra- 
ocular pressure, since the latter depends upon other factors as well, and 
particularly upon the degree of hardness and elasticity of the ocular 
tunics. But in any case it is proportional to the intra-ocular pressure, 
and may therefore be employed in practice as expressive of it. 

Even under normal conditions the ocular tension varies within cer- 
tain limits in different individuals; in general, the eyes of elderly per- 
sons feel harder than those of the young. Hence very slight patho- 
logical changes of tension can only be recognized with certainty as 
morbid, when we can make use of the second, normal eye of the same 
man for purposes of comparison ; greater alterations of pressure, how- 
ever, make themselves evident at once. It has been agreed to denote 
the normal tension by the expression Tn ( I' = tension or tone). Of 
increased tension (hypertony) we distinguish three degrees: T+1, 
T-\- 2, and T-\- 3, which are arbitrarily selected, and indicate approxi- 
mately : tension noticeably increased — greatly increased — hard as stone. 
Similarly, we employ for diminished tension (hypotony) the designa- 
tions T- 1, T-2, and T- 3. 

The intra-ocular pressure plays an important part both under physiological 
conditions and also in diseases of the eye, and has hence been the subject of 
numerous investigations, chiefly experimental. For its exact measurement a 
manometer has been employed, one arm of which is connected with a cannula, 
the other being introduced into the eye. In this way it has been found that in 
the healthy human eye the average pressure equals that of a column of mercury 
twenty-six millimetres high; under pathological conditions (glaucoma) the 
pressure may exceed seventy millimetres (Wahlfors). This method of meas- 
urement, however, is practically inapplicable on account of its being dangerous 
for the eye. Tonometers of various construction have therefore been devised, 
which measure the intra-ocular pressure by being simply placed upon the eye 
and impinging against it ; but none of these instruments have so f&r found their 
way into practice. 

In the assumption above made, that the eyeball is represented by a capsule 
filled with liquid, the lens and its retaining ligament, the zonula of Zinn, are 
left out of consideration. These two together form a diaphragm dividing the 
interior of the eyeball into a smaller anterior and a larger posterior section. 
It is hence possible that the pressure is not the same throughout the whole in- 
terior of the eye, as is assumed above, but that its action is different in the 
anterior chamber from what it is in the cavity of the vitreous, since the dia- 
18 



2Y4 DISEASES OF THE EYE. 

phragm bears a part of the pressure. Under ordinary circumstances, to be sure, 
this is not the case, since the zonula, owing to its elasticity, gives way toward 
the side of less pressure, and hence, in general, the pressure in all parts of the 
eye may be regarded as equally great. Nevertheless, a difference in pressure 
may be developed when the zonula is tightly stretched, as is the case, for ex- 
ample, immediately after the evacuation of the aqueous, when the lens pushes 
forward against the cornea and so tightens the zonula. Then the pressure in the 
anterior chamber is practically nothing, while the pressure in the vitreous main- 
tains a certain height. In this case the difference in pressure induces increased 
filtration of fluid from the vitreous in the anterior chamber — a circumstance 
that contributes to the more speedy replenishment of the chamber. That the 
reaccumulated aqueous really does arise in part from the vitreous, and is not 
simply secreted by the ciliary processes, is proved by the fact that even in the 
dead eye the anterior chamber fills up again within a short time after the aque- 
ous has been evacuated (Deutschmann). And it is on this account that in the 
living eye also repeated punctures of the anterior chamber cause more rapid 
tissue metamorphosis in the vitreous, and hence prove useful in many cases of 
disease of the latter. 



III. Paeticipatiok of the ITtea in the Visual Act. 

63. The iris forms a diaphragm which, as in the case of many 
optical instruments, is interposed between the refracting portions of the 
eye. It has a double task to perform : it prevents an excessive amount 
of light from entering the eye and so dazzling it and injuring the retina, 
and it cuts off the marginal rays. These are the rays that pass through 
the peripl:iery of the cornea and of the lens, and which, being less regu- 
larly refracted, would, unless arrested, impair the sharpness of the reti- 
nal image. In order to be perfectly impermeable to light, the iris has 
a pigment layer on its posterior surface. The iris has the advantage 
over the artificial diaphragms of optical instruments that its size changes 
spontaneously to suit the circumstances of the case. For this purpose 
there exist contracting fibers (sphincter pupillae) and dilating fibers 
(posterior limiting membrane). Moreover, the vessels of the iris must 
be considered as also taking part in this process, since by their disten- 
tion the iris becomes broadened and the pupil consequently contracted, 
and vice versa. 

The contraction of the pupil is governed by the oculo-motor nerve, 
which supplies the sphincter pupillae (and also the ciliary muscle) 
through the ciliary ganglion and the ciliary nerves. By stimulation of 
the oculo-motor nerve, contraction of the pupil is produced; by its 
section or paralysis, dilatation of the pupil. 

Dilatation of the pupil is dependent upon the sympathetic, which 
derives the fibers destined for the pupil from the cilio-spinal center of 
the cervical spinal cord. Irritation of this center or of the cervical 
sympathetic produces dilatation, and paralysis of it contraction of the 
pupil. 



ANATOMY AND PHYSIOLOGY OP THE UVEA. 275 

The reaction of the pupil takes place, involuntarily and uncon- 
sciously. It is either reflex, in which case the stimulus is transmitted 
from centripetal nerve channels to the nerves of the iris, or it is asso- 
ciated, in which case the pupillary fibers of the oculo-motor nerve are 
set into action simultaneously with other fibers of the same nerve. 

The stimulus to reflex reaction of the pupil is set in action — 

1. By light. This produces contraction of the pupil, while con- 
versely as the illumination diminishes the pupil dilates. The reflex arc 
in this case passes through the optic nerve to the nucleus of the oculo- 
motor nerve and along the latter to the eye. The reaction for light 
always affects both eyes — i. e., if the light falls into one eye alone, the 
pupil of the other eye also always contracts (consensual reaction). The 
reaction takes place in both eyes in exactly the same way — that is, ap- 
pears at the same time and reaches the same pitch. The reaction of 
the pupil to light is exceedingly sensitive, and is employed with great 
advantage to determine objectively whether an eye has any sensation of 
light or not (particularly in children, malingerers, etc.). 

2. Toward sensory stimuli, no matter what part of the body they 
affect, the pupil reacts by dilating. Hence, in deep sleep, and also in 
profound narcosis, in which sensory stimuli no longer produce reflexes, 
the pupil is very much contracted, dilating, however, the moment that 
waking from the sleep or from the narcosis occurs. Strong psychic 
stimuli — e. g., fright — in like fashion produce dilatation of the pupil. 

The associated reaction of the pupil always consists of a contrac- 
tion. It occurs — 

1. In convergence (synergy with the internal recti). 

2. In accommodation (synergy with the ciliary muscle). Since 
under physiological conditions every act of accommodation is accom- 
panied by a corresponding convergence, and the contraction of the 
pupil keeps pace with both, we have here as a regular thing a uniform 
consentaneous action of the sphincter pupillse, the ciliary muscle, 
and the internal rectus. These muscles are all supplied by the oculo- 
motor nerve, so that their associated action depends upon a simul- 
taneous excitation of the several bundles of fibers in this nerve sup- 
plying them. 

Since the pupil reacts to stimuli of so many kinds and varying so 
greatly in degree, it is in a state of constant motion. But in every 
case the pupils of the two eyes are equally large. " Inequality of the 
pupils is always a pathological phenomenon. The mean width of the 
pupil differs with the individual and also alters with the age. Very 
greatly contracted in newborn infants, the pupil soon becomes more 
dilated, and then becomes smaller again in manhood, and still more in 
old age. In old people also the reaction of the pupil becomes slug- 
gish, in consequence of the unyielding character of the tissue of the 
iris, and especially of the sphincter (rigidity of the sphincter). 



276 DISEASES OP THE BYE. 

64. Reaction of the Pupil to Poisons. — There is a series of alka- 
loids which produce either dilatation of the pupil (mydriasis) or its 
contraction (miosis).* These substances are accordingly distinguished 
into mydriatics and miotics. They always act upon the ciliary muscle 
in the same manner as upon the sphincter iridis. The most important 
of the mydriatics is atropine, the most important of the miotics are 
eserine and pilocarpine. 

1. Atropine paralyzes the sphincter and the ciliary muscle, and 
hence results in dilatation of the pupil and also in inability to see 
clearly near by. The dilatation of the pupil is a very considerable 
one. If, in the case of a dilatation of the pupil caused by oculo-motor 
paralysis, atropine is instilled, the pupil becomes still more dilated. 
This proves that atropine, besides producing paralysis of the contract- 
ing fibers, causes also stimulation of the dilating fibers. The effect of 
the atropine makes its appearance in from ten to fifteen minutes after 
the instillation, and soon reaches its maximum. Commencing with 
the third day it begins to decrease again, but does not disappear 
completely until after the lapse of a week. The instillation of atro- 
pine, therefore, causes the patient a disturbance of pretty long dura- 
tion, and hence should be employed only when there is good reason 
for it. 

In practice, a one-per-cent solution of sulphate of atropine is most 
frequently employed. If it is desired to obtain a particularly intense 
effect, a granule of the atropine salt in substance is placed in the con- 
junctival sac, where it is dissolved by the tears, and affords a concen- 
trated solution. In this case we must be on the lookout for symptoms 
of general poisoning, which do not ordinarily develop with the instilla- 
tion of the one-per-cent solution. These symptoms consist in a trouble- 
some sense of dryness in the throat, nausea, reddening of the face, and 
subsequently faintness, or even loss of consciousness, and acceleration 
of the pulse. In case of marked poisoning the pupil of the other eye 
also, which has not been treated with atropine, is always dilated. The 
poisoning is effected by the entrance of the atropine into the nose along 
■with the tears and its absorption in excessive quantity by the nasal 
mucous membrane. Hence we may preclude the development of poi- 
sonous symptoms, especially in applying atropine in substance, by pre- 
venting the tears from running down into the nose. For this purpose 
•we draw the lower lid for a short time away from the eyeball, so that 
the tears are poured out upon the cheek, or we compress the lachrymal 
sac with the finger. In serious cases of poisoning, the subcutaneous 
injection of morphine is indicated as the antidote. 

* From /ifiaitns, contraction ; hence miosis, and not myosis, as it is generally 
written (Hirschberg). The derivation of fivSplaa-is is uncertain. This word was 
already used by the ancients to signify dilatation of the pupil, and also the blind- 
ness that is so frequently associated with it. 



ANATOMY AND PHTSIOLOaY OF THE UVEA. 271 

We are not to conceive of the action of atropine upon the pupil in 
the same light as if it had got by absorption into the circulation, as 
is the case when it is administered internally. For in this case the 
pupils of both eyes would necessarily be dilated, while, as a matter of 
fact, the dilatation of the pupil occurs only on the side in which the 
instillation has been made. The action, accordingly, is a local one, and 
takes place from the atropine passing through the cornea by diSusion 
and getting into the aqueous humor so as to act directly upon the iris. 
We can prove this by a simple experiment, by dropping atropine into 
one eye, and, as soon as the pupil has dilated, evacuating the aqueous 
by paracentesis. If, then, this aqueous is introduced into the other 
eye, it excites a dilatation of the pupil in the latter — a proof that it con- 
tains atropine. In a similar way is the action of the other mydriatics 
and miotics upon the iris to be explained. 

2. Eserine (also called physostigmine) has an action exactly the 
opposite of that of atropine, since it places the sphincter iridis and the 
ciliary muscle in a state of tonic contraction. Consequently, miosis 
develops so that the pupil is about the size of a pin's head, with adjust- 
ment of the eye for the near point, as if marked myopia were present. 
We generally apply sulphate of eserine in one-per-cent solution. This 
solution, when freshly prepared, is colorless, but after some days be- 
comes red, although without losing its activity. The instillation of 
eserine produces, simultaneously with the changes in the iris, a feeling 
of great tension in the eye, and often also headache and even nausea, 
so that with many persons it can not be employed. For tliis reason 
hydrochloride of pilocarpine, prescribed in a one- to two-per-cent solu- 
tion, is recommended as a miotic for ordinary use. Its solution keeps 
better than that of eserine, and does not act as powerfully as the latter, 
but is not accompanied by any unpleasant complications. Eserine is 
best reserved for those cases in which pilocarpine is ineffectual. 

The action of miotics is of shorter duration than that of the mydri- 
atics, and is also less powerful. Hence a pupil contracted by eserine or 
pilocarpine can be dilated by atropine, but a pupil dilated by atropine 
can not be contracted by a miotic. 

3. Cocaine dilates the pupil, and hence would seem to call for men- 
tion in this place, although, strictly speaking, it does not belong to the 
mydriatics proper— that is, the dilatation of the pupil by cocaine is not 
produced, as in their case, by a paralysis of the sphincter pupilla, but 
simply by contraction of the dilator fibers and also by constriction of 
the blood-vessels of the iris. The dilatation of the pupil is therefore 
only a moderate one, and the reaction of the pupil to light persists ; 
moreover, mydriatics and miotics still produce an effect. If cocaine is 
instilled into an eye the pupil of which has been dilated by atropine, 
the dilatation increases somewhat ; hence the mydriasis produced by 
the simultaneous action of atropine and cocaine is the most consider- 



278 DISEASES OP THE EYE. 

able that can possibly be attained. The accommodation is not par- 
alyzed by cocaine, but only somewhat weakened. 

Besides acting upon the iris, cocaine produces also the following 
effects: The conjunctiva becomes very pale, and at the same time the 
patient has a feeling of cold in the eye. The palpebral fissure is more 
widely open and the act of winking is less frequent, so that the cornea 
may readily become dry upon its surface. Sometimes the eye is pro- 
truded somewhat forward, and the intra-ocular tension slightly dimin- 
ished. The practically important phenomenon, however, is the antes- 
thesia shown by the superficial tissues of the eye (cornea and con- 
junctiva). 

The effects of cocaine are best explained upon the assumption that 
it acts as a stimulant to the fibers of the sympathetic. The contrac- 
tion of the vessels thus produced causes the pallor of the conjunctiva; 
the contraction of the superior and inferior palpebral muscles (see 
§ 105), which are also supplied by the sympathetic, is the cause of the 
dilatation of the palpebral fissure ; and the contraction of the iridic ves- 
sels combines with the contraction of the dilator fibers of the iris in 
producing the mydriasis. Whether the anaesthesia of the surface of the 
eyeball is to be referred to its bloodless state or not, has not yet been 
determined with certainty. Owing to this ansesthesia the reflex move- 
ments of the lids are abrogated. 

Cocaine was introduced into ophthalmology by Koller, and is em- 
ployed under the form of the hydrochloride in a two- to five-per-cent 
solution. Its most frequent use is to produce anajsthesia for the per- 
formance of operations (see § 151) ; in addition, it is instilled to ame- 
liorate the pain in superficial inflammations, especially of the cornea, 
and also to diminish photophobia and blepharospasm. It may also be 
employed to dilate the pupil for examination with the ophthalmoscope. 

The ciliary body takes part in the visual act, since it contains the 
ciliary muscle, which provides for accommodation (see § 139). The 
ciliary muscle acts synergetically with the sphincter pupillae, and, like 
it, is paralyzed by mydriatics and thrown into spasms by miotics. 

The cliorioid takes part in the visual act inasmuch as it supplies 
the visual purple, and also because its pigment, together with the pig- 
ment epithelium of the retina, forms the dark coating of the interior 
of the eye, which is essential for the distinctness of the retinal images. 

Besides the physiological forces (muscular and elastic fibers), which alter the 
width of the pupil, there are purely mechanical factors which require consid- 
eration in this connection. This is the case, for instance, with the contraction 
of the pupil that regularly occurs when the aqueous escapes. This contraction 
is of practical importance in the performance of many operations. When, for 
instance, we perform discission of cataract through the cornea, we take care 
not to let the aqueous escape, since the consequent contraction of the pupil 
would expose the iris to greater pressure from the swelling lens. That this con- 



ANATOMY AND PHYSIOLOGY OF THE UVEA. ^79 

traction owes its origin to purely mechanical causes, is deduced from the fact 
that it occurs even in the eye of a dead man when the aqueous is evacuated. 

Dilatation of the pupil manifests itself by a sense of dazzling. Sometimes 
the patients also allege that objects appear smaller (micropsia). This phenome- 
non, however, does not depend upon the dilatation of the pupil, but upon the 
paralysis of accommodation, which is generally present at the same time, and is 
therefore also observed when the latter alone is present. (For its explanation 
see under paralysis of accommodation, § 150.) Conversely, in contraction of 
the pupil, sometimes-i. e., if spasm of accommodation is at the same time 
present— objects appear larger (macropsia). Moreover, obscuration of vision is 
often complained of, because less light enters the eye through the contracted 
pupil. In very marked miosis, whether occurring after the employment of 
miotics or appearing spontaneously (e. g., as the result of tabes), the pupil is 
frequently found to be irregular and slightly angular, although no synechi* 
exist. 

The reaction of the pupil to light is a very valuable sign of the presence of 
perception of light : in the first place, because it is exceedingly sensitive ; and, 
secondly, because it demonstrates the existence of perception of light independ- 
ently of the statements of the patient. Its usefulness is still further enhanced 
by its disclosing in the pupils of both eyes (through the consensual reaction) 
the perception of light by one eye. How is this consensual reaction efiEected ? 
From the retina of each eye (e. g., the right eye, M, Fig. 83) fibers pass through 
the chiasm partly into the right, partly into the left optic tract (Fig. 83, T and 
Ti). From these the stimulus is transmitted directly to both right and left 
oculo-motor nuclei {Kand A'l) ; then each nucleus sets up a contraction of the 
pupil on its own side. The consensual reaction, therefore, is really as direct as 
is the pupillary reaction of the illuminated eye itself. 

The result of the consensual reaction is that under normal conditions both 
pupils must be of equal diameter, even if only one of the eyes is exposed to the 
impact of light, or if the sensitiveness of the two eyes to light is difierent. 
Inequality of the pupOs (anisocoria) is always pathological. For the reasons 
given it can never take its origin from the centripetal fibers (optic-nerve fibers), 
but is always caused by a disturbance in the centrifugal channels (oculo-motor 
nerve and its center). 

In testing the perception of light by the reaction of the pupils, we must not 
lose sight of the fact that there are cases in which, although the perception of 
light is present, the reaction is absent ; and, conversely, cases in which, with 
good reaction, there is yet no perception of light. 

(o) The cases in which the pupil does not react to light, although the percep- 
tion of light is present, are frequent. The iris may be paralyzed either artificially 
by mydriatics, or by disease, such as oculo-motor paralysis or paralysis of the 
nerves of the iris due to increase of tension or to inflammation. In the same 
category belong those cases in which the iris is mechanically prevented from 
moving by adhesions to the posterior capsule of the lens or to the cornea. In 
all these cases, however, consensual reaction of the pupil takes place in the 
other eye, provided that that is healthy. The test for the perception of light 
in such a case, then, would be performed by alternately exposing to light and 
•screening the eye to be tested, and meanwhile watching the pupil of the other 
eye for any movements that it might make. 

The absence of the reaction to light can also be caused by an interruption in 



280 



DISEASES OF THE EYE. 



the course of the reflex arc. This occurs in spinal diseases, particularly in tabes 
dorsalis; also in progressive paralysis. In these cases the pupil is either found 




,— ' Accommodation 
Convergence 



Fig. 83.— Schematic Representation of the Optic Tracts. 

The field of vision common to the two eyes is composed of a right half, (?, and a left half, Gi. 
The former corresponds to the left halves, I and Zj, of the two retinae, the latter to the right 
halves, r and r^ . The boundary between the two halves of the retina is formed by the vertical 
meridian. This passes through the fovea centrahs, /, in which the visual line ( V) drawn from 
the point of fixation, i^, impinges upon the retina. The optic nerve fibers arising from the 
right halves, r and r,, of the two retinae (indicated by the dotted line") all pass into the right 
optic tract, T, while the fibers belonfjing to the left halves, I and l^ , of the two retinae pass into 
the left optic tract, Tj. The fibers of each optic tract for the most part pass to the cortex of 
the occipital lobe, S, forming Gratiolefs optic radiation, S ; the smaller portion of them, m, 
goes to the oculo-motor nucleus, K. This consists of a series of partial nuclei, the most 
anterior of which sends fibers, P, to the pupil (sphincter iridis) ; the next one sends fibers, A^ 
to the muscle of accommodation ; and the third sends fibers, C, to the converginc: muscle 
(internal rectus, i). All three bundles of fibers run to the eye in the trunk of the oculo- 
motor nerve, Oc. Division of the optic tract at o g or at e e produces right hemiopia ; and in 
the former case there would be no reaction to light on illuminating the left half of either 
retina. Division of the chiasm at s s produces temporal hemiopia. Division of the fibers, th, 
abolishes the reaction of the pupil to light, but leaves the sight and also the associated con- 
traction of the pupil in accommodation and convergence unaffected. 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 281 

to be perfectly immobile, or its reaction for accommodation and convergence is 
retained, while the reaction for light has disappeared {Argyll- Robertson pupil). 
In the latter case the reflex arc running from the optic nerve to the oculo-motor 
nucleus is interrupted (Fig. 83, m), while the connections of the centers for the 
pupil, for accommodation, and for convergence, which adjoin each other in the 
oculo-motor nucleus, are undisturbed. 

The reflex immobility of the pupil in tabes dorsalis and in progressive paral- 
ysis is generally combined with a marked contraction of the pupil (so-called 
spinal miosis), but it also is found at times with a normally wide or even with a 
dilated pupil. 

(J) It also happens that the reaction of the pupil to light is present, mthout 
there being any perception of light. This occurs when the lesion is situated high 
up in the optic tract. The fibers of the optic nerve ascend to the cerebral 
hemispheres and terminate in the cortex of the occipital lobe {B, Fig. 83). But, 
some time before this takes place, those fibers (ot) of the reflex arc, which pass 
to the center of the pupillary movements, branch off from the optic tract. If, 
then, the optic tract is interrupted above the place where they are given oS 
(e. g., at ee), stimulation of the optic nerve fibers no longer reaches the cere- 
bral cortex and hence excites no perception, and yet the pupillary reflex is still 
regularly produced. The same thing would happen if the cerebral cortex itself 
were through some lesion incapacitated for performing its functions. In these 
cases, however, the lesion of the optic tracts [or of the cortex] would have to be 
bilateral, as otherwise hemiopia and not blindness would be present (see § 100). 
For this reason it is clear why such cases, in which blindness exists, even 
though the examination of the eye gives negative results and the reaction of 
,the pupil to light is preserved, are very rare (occurring, for example, in ursemic 
amaurosis, see § 96), so that under these circumstances our first thouglit would 
be of simulation or of hysteria, and we would examine for these conditions first. 

In general, the pupil dilates upon the application of sensory stimuli. An 
exception to this rule is when the stimuli act intensely upon the eye itself. In 
this case the pupil contracts, and does so in consequence of the hypersemia of 
the iris produced by the stimulus (see § 66). 



Atropine is such an efficient mydriatic that exceedingly small quantities— 
the millionth part of a gramme— suffice to dilate the pupil. Sometimes all that 
we have to do in order to get a dilatation of our own pupils is to instill 
atropine into another person's eye, and in so doing moisten our fingers and then 
through carelessness touch our own eyes with them. Dilatation of the pupil 
may also be produced by the internal use of atropine or of drugs which contain 
it. The most frequent occurrence of this sort is when patients who take bella- 
donna internally complain of being dazzled, and of not seeing well near by in 
their work. We find in such cases moderate dilatation of the pupil and dimi- 
nution in the power of accommodation. 

With many people there exists an intolerance of atropine. This manifests 
itself in various ways : (a) By the development of toxic symptoms, such as dry- 
ness in the throat or nausea, with even small doses. This is especially apt to 
occur after the long-continued use of atropine. (J) By the production of a 
catarrh (atropine catarrh), which is usually characterized by the formation of 
numerous follicles. Here, again, a pretty long-continued use of atropine is re- 



282 DISEASES OF THE BYE. 

quired to produce the effect, (c) In many persons a single drop of atropine is 
enough to bring on marked redness and swelling of the lids, looking like an 
attack of erysipelas. In these and similar cases the atropine must either be 
simply abandoned, or be replaced by another mydriatic, according to circum- 
stances. Among the other mydriatics that we are acquainted with are hyoscy- 
amine (isomeric with atropine), scopolamine (formerly known as hyoscine), du- 
boisine (a mixture of hyoscyamine, hyoscine, and of other alkaloids, whose 
nature is not very precisely known), homatropine (prepared synthetically by 
Ladenburg from tropine and mandelic acid), ephedrine, pseudo-ephedrine, and 
gelsemine. Of the alkaloids mentioned, only three are at all in frequent use — 
namely, duboisine and scopolamine on the one hand, and homatropine on the 
other. Sulphate of duboisine acts like atropine, scopolamine hydrobromide more 
intensely, and both are employed instead of it in those cases in which it is 
not tolerated. Homatropine hydrobromide has a feebler and, what is most im- 
portant, a less enduring action than atropine, its effects lasting for scarcely 
more than about five hours.* It is hence a valuable agent when a transient 
dilatation of the pupil for purposes of examination of the eye is all that is 
required. 

Eserine is the most efficient of the miotics, but is frequently not well borne, 
because in many cases it excites violent headache, which may lead to vomiting. 
These symptoms are not to be regarded as due to a general poisoning, but are 
caused by the marked contraction of the pupil, by which the nerves of the iris 
are strongly pulled upon. Hence, the symptoms are absent when marked con- 
traction of the pupil fails to take place — e. g., in atrophy of the iris or in solu- 
tions of continuity of the sphincter (colobomata, fissures, etc.). In such cases 
eserine should be preferred to pilocarpine. 

Pilocarpine is employed in ophthalmology by two entirely different methods 
— locally by instillation into the eye, and internally in the shape of a hypodermic 
injection. In the first way it is much employed for contracting the pupil, and 
especially for diminishing the intra-ocular pressure in glaucoma. 

In subcutaneous injection (of 0.01 to 0.03 gm. per dose) pilocarpine is used 
to produce diaphoresis. If, as happens with many patients, it produces great 
nausea, diaphoresis may be effected by means of sodium salicylate. Of the latter 
salt the patient takes 1 to 3 gm. in a cup of hot tea (linden flower or elder tea) or 
of hot lemonade, and stays, covered up warm, in bed. In this case the specific 
action of the salicyl is combined with the diaphoresis. All patients, however, do 
not sweat sufficiently under the administration of sodium salicylate, and in others 
the latter excites digestive disturbance. In such cases diaphoresis may be pro- 
duced by a hot bath, upon leaving which the patient is wrapped in a dry woolen 
blanket and put to bed, for some hours. This method produces abundant trans- 
piration with a fair degree of certainty and without special bad consequences, 
but owing to the circumstances of the case is not always applicable. Diapho- 
resis may be induced every day, or every other day, according to the patient's 
strength. During the treatment the patient should take altogether as little 
liquid as possible, since what we are trying to effect is the absorption of patho- 
logical effusions by the removal of a quantity of water from the tissues. 

[* With solutions of homatropine of the strength usually employed for testing 
the refraction (two to three per cent), the effect on the pupil and the accommoda- 
tion lasts from twenty-four to thirty-six hours. — D.] 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 



283 



Diaphoretic treatment is contra-indicated in heart disease and marked 
atheroma of the arteries; and pilocarpine in particular is contra-indicated in 
pregnancy. 

Diaphoresis is much employed in ophthalmology, and mainly (1) in violent 
acute inflammations, especially scleritis, irido-cyclitis, chorioiditis, retinitis, and 
retrobulbar neuritis ; (3) for clearing up opacities of the vitreous ; (3) for pro- 
ducing absorption of cfiused blood; (4) in detachment of the retina; (5) in 
rheumatic paralyses. 

Both the mydriatics and the miotics may be introduced into the eye in the 
form of an ointment, instead of in solution. Small gelatin disks containing a 
certain quantity of the alkaloid are also made, which, when introduced into the 
conjunctival sac, become dissolved and so develop their activity. 

What eftect do mydriatics and miotics exert upon the intra-ocular pressure ? 
So far, observers have not arrived at concordant results in regard to this matter, 
but at least this much has been proved by experiments, that in the healthy eye 
the alkaloids cause only very insignificant variations of tension. The case is 
altogether different when elevation of tension exists, or there is a tendency to 
it; then atropine may raise the tension very considerably, while eserine and 
pilocarpine noticeably diminish it. 

Besides cocaine, holocaine and eueaine have recently been employed as anaes- 
thetics. 



IV. Development of the Eye. 

65. The eye develops from a protrusion which forms on both sides 
of the first cerebral vesicle. This invagination, which is called the 
primitive ocular vesicle (Fig. 84, a), remains in connection with the 
cerebral vesicle by means of a pedicle, which, 
at first broad, afterward more narrow, be- 
comes subsequently the optic nerve {b). Its 
surface is covered by the ectoderm {E E). 
Upon this ectoderm, at a point correspond- 
ing to the apex of the ocular vesicle, there 
soon forms a thickening. This is the first 
rudiment of the lens, and the way in which 
it is formed is that the ectoderm here grows 
thicker, becomes folded upon itself, and forms 
an everted pouch directed toward the ocular 
vesicle {L, Fig. 85). This pouch deepens, 
and finally becomes shut in in front so as to 
form a closed sac, the lens vesicle (A Fig. 
87 B). The lens is accordingly an epithelial 
structure,' being a derivative of the external 
germinal layer, and in the beginning consists 
of a hollow vesicle, which afterward becomes 
filled up by the growth of its cells and is con- 
verted into a solid sphere. 

In proportion as the ectoderm at the site 




Fig. 84.— Section through the 
Embryonic Eye at a Period 
of i)£velopment correspond- 
ing to that of a human em- 
BRYO OP Twenty-one Days. 
Magnified 100 x 1. 

The primitive ocular vesicle, a, 
is a protrusion from the first 
cerebral vesicle, 6, from which 
it is separated by a shallow 
constriction. It is surrounded 
by the cells of the mesoderm, 
Jlf, over which passes the ec- 
toderm, E, consisting for the 
most part of a single layer of 
cells. 



284 



DISEASES OP THE EYE. 



of the primitive lens pushes against the ocular vesicle, the surface of 
the latter is indented. Thus a flask-shaped structure with double walls 
is formed out of what was once a round sac (Pig. 86). This is called 
the secondary ocular vesicle, which is hence the primitive ocular vesicle 





Fig. 85. 



FiQ. 86. 



Fig. 85.— -Section through the Embryonic Eye at a Period of Development correspond- 
ing TO that of a Human Embryo of Twenty-two to Twenty-five Days. Magnified 
100 X 1. 

The vertically made section passes through the fcetal ocular fissure. The ectoderm, E, dips in 
somewhat at the site o£ the lens-proton, i, and besides is thickened, being made up here o£ 
several layers of cells. Corresponding to this in-dipping, the ocular vesicle, a, presents an 
indentation in its cavity, and is consequently converted into the ocular cup, the inner wall, 
r, of which subsequently becomes the retina, the outer wall, p, becoming the pigment epi- 
thelium. The interior of the ocular cup communicates with the first cerebral vesicle, 6, 
through the optic-nerve proton, o. The projecting portion of the wall of the ocular cup is 
wanting below, because the foetal ocular cleft is situated here. M, mesoderm, in which, 
near the lower edge of the rudimentary lens, can be seen the cross section of a capillary 



Fig. 86.— Section through the Embryonic Eye at a Period of Development correspond- 
ing to that of a Human Embryo of Twenty-four to Twenty-five Days. Magnified 
100 X 1. 

The section here depicted does not pass through the fcetal ocular cleft, so that the secondary 
ocular vesicle appears as a complete cup ; the more so since the portion of ectoderm, .E, 
representing the rudimentary lens, L^ has become invaginated further than in Fig. H5. 
In the bottom of the depression occupied by the lens there lies some cell detritus, and be- 
tween the lens and the inner wall of the ocular cup are seen a few cells derived from the 
mesoderm, M. In one or two spots in the mesoderm are visible the cross sections of capil- 
laries. 0, rudimentary optic nerve. 



that has been invaginated and thus, so to speak, reduplicated. From 
the ocular vesicle is subsequently formed the retina, which thus must 
be looked upon as an isolated portion of the brain itself. The exterior 
and interior layer of the secondary ocular vesicle become differentiated 
early. In Fig. 87 B, the inner layer, r, is seen to be already consider- 
ably thicker than the external, p, although the latter also consists of 
several rows of cells. The exterior layer later becomes composed of 
a single row of cells, takes up pigment (Fig. 88), and ultimately 
becomes the pigment epithelium, which therefore is rightly counted in 
with the retina. The interior layer (?•) soon gets to surpass the exterior 
one considerably in thickness, especially at the posterior portion of the 
eye, where its cells acquire a radial arrangement and develop into the 
retina proper. The anterior margin of the ocular vesicle, where the 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 



285 



two layers become continuous, corresponds to the margin of the pupil 
in the fully developed eye (Fig. 89). 

At the time when the indenting of the ocular vesicle by the lens 
takes place, the latter completely fills the cavity of the vesicle, no vitre- 
ous as yet existing. This latter is essentially connective tissue, and is 
derived from the mesoderm, which sur- 
rounds the ophthalmic vesicle (Fig. 84, ^ 
M), and which makes its way into the ^ 
interior of the latter through an open- jif 
ing — the festal ocular cleft — in its lower ., . ••.•.; 





Fig. 87. —Secondary Ocular Vesicle with Ocular Fissure op the Left Eye op a Human 
Foetus Twenty-seven Days Old. Magnified y8 x 1. 

A. — Ocular vesicle seen from in front and a little below. The drawing is taken from a model 
which Prof. Hochstetter has made from his dissections by the plate-model method. The 
model represents the rudimentary brain with its processes, but omitting the ectoderm and 
mesoderm. The eye rises by a thick hollow pedicle from the lateral wall of the first cere- 
bral vesicle, G. At its distal end it presents an indentation, L, which corresponds to the 
invagination of the lens vesicle into the ocular vesicle. The limits of the lens vesicle are 
indicated by a dotted curved line. From the lower margin of the indentation runs the f cetal 
ocular cleft. This, at first very narrow, afterward widens .somewhat, and extends down 
upon the pedicle of the optic vesicle. 

B.— Ocular vesicle seen in vertical section. Out of the numerous sections combined to form the 
drawing A, the one selected for representation in B is that passing precisely through the 
ocular cleft; hence the lower wall of the ocular fissure is wanting here, just as it is in Fig. 
8.5. The walls of the first cerebral vesicle, (?, approach each other and form the pedicle of 
the ocular vesicle (o, subsequently the optic nerve), and further along form the reduplicated 
wall of the secondary ocular vesicle. The external lamina, p, of this reduplicated wall, 
which later is transformed into the pigment epithelium, composed of a single layer of cells, 
is at this time still destitute of pigment and composed of several layers of cells. At the 
anterior border of the ocular vesicle it is reflected to form the thick inner lamina, r. This 
latter, from which the retina proper is developed, is already beginning to show a radial 
arrangement of nuclei. The anterior border of the ocular vesicle is covered by the ecto- 
derm, E, E, upon which is the rudimentary lens, L. which has already become closed so as 
to form a vesicle, but is not yet completely detached. Above, the mesoderm, M, fills the 
space between the cerebral vesicle, the ocular vesicle, and ectoderm; but below, the meso- 
derm, wherever the ocular cleft extends, penetrates into the interior of the ocular cup till it 
reaolies the lens vesicle. 



side. Even as early as the time when the ocular vesicle is undergoing 
invagination so as to form a flask, we notice that at one spot in its 
lower side the wall of the flask is altogether deficient (Figs. 85 and 
87 B). Here, then, a fissurelike defect exists in the wall of the flask, 
a defect which is continued backward upon the pedicle of the ocular 
vesicle (the optic nerve) in the form of a furrow (Fig. 87 A). Through 
this fissure the mesoderm gradually grows from the outside into the 
interior of the eye, pushing its way in between the retina and the lens, 



286 DISEASES OF THE EYE. 

separating them from each other, and itself becoming transformed into 
the vitreous. Subsequently the margins of the fissure unite so that 
the eye again forms a closed yesicle. The vitreous is thus cut off from 
its connection with the portions of the mesoderm that lie without, and 
which produce the uvea and the sclera. 

The channel in the optic nerve, which represents the continuation 
backward of the ocular cleft (Fig. 87 A), is also filled in by mesoder- 
mal tissue. When, then, the margins of this channel afterward become 
united in the same way as is the case with the cleft in the eyeball 
itself, this tissue, which is derived from the mesoderm, is shut up here, 
and retains none of its former connections save those existing anteriorly 
with its continuation, the vitreous. This tissue afterward develops 
into vessels running along in the eye stalk or optic nerve, which ac- 
cordingly incloses them. They constitute the central vessels of the 
optic nerve, and are continued forward into the vitreous as the vessels 
of the latter (Fig. 88). The vessels in the embryonic eye are, in fact, 
disposed as follows : The central artery of the optic nerve continues its 
course as the arteria centralis corporis vitrei or arteria hyaloidea (Fig. 
88), through the vitreous to the posterior pole of the lens, lying in the 
central canal of the vitreous (canalis hyaloideus sen Cloqueti). Fur- 
thermore, as it enters the eye, the central artery of the optic nerve 
gives o£E lateral branches which form an arterial network in the periph- 
eral portions of the vitreous (vasa hyaloidea propria — not yet present 
in the eye that is represented in Fig. 88), and likewise extend forward 
to the margin of the lens. The arteria centralis corporis vitrei, upon 
arriving at the posterior pole of the lens, divides into branches, ramify- 
ing over the posterior surface of the lens and running forward to the 
margin of the latter, where the anterior extremities of the vasa hya- 
loidea propria unite with them and form a specially dense network of 
vessels surrounding the border of the lens. In front of the equator of 
the lens there are other branches that run to this vascular network, 
turning round the anterior border of the ocular cup to reach it. These 
are derived from that portion of the mesoderm that afterward forms 
the uvea. They assist in covering also the anterior capsule of the lens 
with a vascular network. Among the vessels derived from the uvea 
are found veins as well as arteries, and these uveal veins provide for 
the escape of all the blood, since all the other vessels going to the lens 
are arteries. The lens in the foetal eye is accordingly surrounded by a 
vascular membrane, the tunica vasculosa lentis, which in the region oc- 
cupied by the pupil bears the name of pupillary membrane (mem- 
brana pupillaris, M, Fig. 89), while its remaining portion is known as 
the membrana capsularis ((7, Fig. 89). The tunica vasculosa lentis 
disappears in the last two months before birth, although scattered rem- 
nants of the pupillary membrane are quite frequently found still pres- 
ent in newborn infants. 



ANATOMY AND PHYSIOLOGY OF THE UVEA. 



287 



The vessels of the retina develop by growing out from vessels that 
extend from the optic-nerve entrance out upon the inner surface of the 




Fig. 88.— Section through an Eye at a Period op Development Corresponding to that of 
A. Human Embryo in the Middle of the Third Month. Magnified 73 x 1. 

The envelope of the ocular vesicle is formed of mesoderm, and in its anterior segment consists 
of the cornea, which contains an abundance of nuclei throughout and a particularly 
marked accumulation of nuclei separating it from the posterior segment. In this posterior 
segment no delimitation between sclera and uvea has as yet taken place. The uvea will 
develop from the inner layers, which are distinguished by containing more nuclei— a char- 
acteristic which is continued over into the hindmost, or uveal, laj eis of the cornea. At a 
point corresponding to the anterior margin of the ocular vesicle the mesoderm projects into 
the interior of the eye, and from the free border of the ring-shaped process thus formed 
rise two delicate vascular membranes which surround the lens, constituting a sort of vascu- 
lar lenticular capsule. Into the hinder of these two membranes the hyaloid artery enters 
at a point corresponding to the posterior pole of the lens. This artery rises from the central 
artery, C, of the optic nerve. Of the two laminae composing the secondary ocular vesicle, 
the external, or pigment epithelium, has been reduced in its posterior part to a single layer 
of cells, while in its anterior portion there are still several cell layers present which have 
already taken up pigment. The inner lamina, or retina, consists of numerous layers of 
cells, the nuclei of wliich show a partially radial arrangement. In the immediate vicinity 
of the optic-nerve entrance can be seen the way in which one lamina is reflected into the 
other. The anterior point of reflection corresponds to what is later the pupillary margin of 
the iris. The lens is of an almost sphei'ical shape; its antero-posterior diameter, in fact, is 
actually somewhat larger than its equatorial. Upon the anterior surface of the lens lies the 
epithehum. which still consists of several layers of cells; and no distinct lens capsule has 
yet been differentiated. In the region of what is later the equator of the lens the epithelial 
cells are growing out into lens fibers, which are still nucleated tliroughout, and take a sagit- 
tal direction. The posterior surface of the lens is destitute of epithelium, and is covered by 
an extremely delicate capsule. The vitreous cavity is very small. X, L^, the eyelids grow- 
ing out. 

retina, while the vessels of the vitreous, previously present, undergo ob- 
literation. 

The mesoderm that envelops the ocular vesicle forms through its 
outer layers the cornea and sclera, and through its inner layers the 
uvea. The most anterior portions of the latter — i. e., the ciliary body 
and iris— arise from that layer of the mesoderm which, jutting out like 
a spur into the interior of the eye, covers the anterior, tapering portion 



288 



DISEASES OP THE EYE. 



of the wall of the vesicle (Fig. 89), which itself furnishes the inner 
lining for both these structures. Over the ciliary body it is only the 
external lamina of the ocular vesicle that is pigmented, while from the 
non-pigmented layer of cells constituting the internal lamina the pars 
ciliaris retinae is formed. Farther forward, over an area corresponding 
to the posterior surface of the mesodermal rudimentary iris, both lam- 
inae of the ocular vesicle are pigmented, and th§ two unite after under- 




FiG. 89.— Anterior Segment of the Eye at a Period of Development corresponding to 
THAT OF A Human Embryo at the End of the Third Month. Magnified 80 x 1. 

The epithelium of the cornea, ff, is continued over upon the conjunctiva as far as the retrotar- 
sal fold, U. Behind the cornea is seen the front wall of the ocular vesicle. The two laminae 
forming this wall are reflected so as to unite with each other at a point corresponding to 
the margin of the pupil. The external lamina, P, is pigmented throughout, the internal 
lamina being pigmented only in its anterior portion, where it later is converted into the pos- 
terior stratum of the retinal pigment layer of the iris. Farther back, where the inner 
lamina is destitute of pigment, it is afterward converted into the pars ciliaris retinae, which 
lines the ciliary body, and is composed of a single layer of cells. Still farther back a sud- 
den swelling out of the inner lamina denotes the beginning of the retina proper, r, at a spot 
corresponding to what is afterward the ora serrata. The two lamln£e of the ocular vesicle, 
so far as they constitute the coating of the ciliary body, lie closel.v applied to the mesoder- 
mal envelope. Farther forward, at a point corresponding to the rudimentary iris, they 
separate from the cornea, from which they receive a covering of mesodermal tissue, after- 
ward converted into the stroma of the iris. From the free border of this tissue are given 
off two membranes— the membrana pupillaris, il/, which passes to the opposite pupillary bor- 
der, and the membrana capsularis, (7, which runs backward, between ciliary body and lens, 
to the posterior surface of the latter. In the lens, L, the circle of nuclei is carried farther 
forward than in Fig. 88, and the shape of the lens in cross section has already become more 
elliptical. 



going reflection at the border of the pupil. Conjointly they form the 
retinal pigment layer of the iris (see pages 253, 256). 

The lids originate as folds, which keep growing out above and be- 
low the eye from the skin surrounding it, until their edges come into 
contact. They then become united to each other, but only by their 
epithelial lining ; and shortly before birth this union of the two is dis- 
solved again. 

The lachrymal gland originates from a budlike intrusion of the 
epithelium of the conjunctiva into the orbital tissue. The lachrymal 
canal starts from a channel which exists even at an early period be- 
tween the superior maxillary and the nasal processes. 



CHAPTER V. 
DISEASES OF THE IRIS AND OF THE CILIARY BODY. 

I. Inflammation. 

66. The iris and the ciliary body form a continuous whole, inas- 
much as the iris springs from the ciliary body ; both, moreover, are 
supplied by the same blood-vessels. It is hence quite easy to under- 
stand that both organs are very frequently diseased at the same time. 
Unmixed inflammation of the iris (iritis) or of the ciliary body 
(cyclitis) is rare ; in most cases we have to do with a combination of 
the two (irido-cyclitis). For practical reasons, however, it is advisable 
first to describe the symptoms of iritis and of cyclitis separately, and 
then show what sort of clinical picture is produced by their combi- 
nation. 

Symptoms of Iritis. — The symptoms of iritis are partly referable to 
the hypersemia of the iris, partly to the formation of exudation. 

HypercBmia of the iris manifests itself chiefly by the discoloration 
which causes a blue or gray iris to appear greenish — a change which is 
particularly striking when comparison is made with the iris of the 
other eye, in case this is healthy. In dark eyes the discoloration is less 
pronounced. Sometimes, with the aid of a magnifying glass, we can 
clearly distinguish the separated dilated blood-vessels under the form 
of red strife or maculae. The other changes found concern the pupil, 
which is contracted, and does not react as well as usual. The contrac- 
tion is a necessary result of the dilatation of the iris due to the in- 
creased fullness of the vessels ; besides, there is a spasm of the sphincter 
produced by the irritation. For these reasons the reaction of the iris 
to light is diminished, and atropine also acts less promptly and less 
thoroughly than usual. The hypersemia of the iris is accompanied 
by ciliary injection, photophobia, and increase of the lachrymal secre- 
tion. 

The symptoms of congestion just described may exist by them- 
selves without symptoms of exudation, iu which case we do not speak 
of iritis, but merely of hyperemia iridis. This is observed as a result 
of the same causes as iritis itself, in case the irritation is not great 
enough to provoke actual inflammation. Pure hyperemia of the iris 
is most frequently seen in corneal afEections, and particularly in case 
19- 289 



290 



DISEASES OP THE EYE. 



of small ulcers or foreign bodies in the cornea. Hyperasmia of the iris, 
provided it is not the precursor of an iritis, disappears without leaving 
any lasting traces of its presence. 

Exudation takes place partly into the tissue of the iris itself, partly 
into the surrounding cavities, the anterior and posterior chambers, and 

is accordingly characterized by varying 

symptoms : 

1. Exudation iiito the tissue of the 
iris makes the latter, since it is filled 
with an abundance of round cells, ap- 
pear swollen and thicker than usual. 
The discoloration is still more pro- 
nounced than in simple hypertemia, the 
distinctness of the markings upon the 
anterior surface of the iris being ob- 
scured. It is easy to understand that 
the rigid and swollen iris should react 
but insufficiently to light ; the pupil is 
greatly contracted. 

2. Exudation into the anterior 
chamber manifests itself first by tur- 
bidity of the aqueous, in which numer- 
ous exudation cells are suspended. The 
turbidity is best recognized upon the 
dark background of the pupil, which 
in this case looks gray instead of being 
a pure black. Gradually the formed 
constituents floating in the aqueous 
sink to the bottom of the chamber, 
where they produce a hypopyon (Fig- 
53). When there is very great hyperse- 
mia, rupture of the blood-vessels in the 
iris may take place with an extravasa- 
tion of blood, which also sinks to the 
bottom of the anterior chamber (hy- 
phsema). 

Besides the exudates suspended in the aqueous, a layer of exudate 
is also found covering the walls of the anterior chamber. Hence the 
cornea presents a uniform delicate cloudiness. Moreover, the layer of 
exudate deposited upon the iris (Kg. 90) contributes essentially to the 
hazy appearance of the iris markings. The layer of exudate extends 
from the iris upon the anterior capsule of the lens (Fig. 91, «), and 
covers the latter throughout the area of the pupil, which consequently 
appears gray. 

If this exudate becomes organized, a membrane is produced which 




Iritis. Magnified 116 x 1. 



Upon the surface of the iris is a layer 
of exudate, E, consisting mainly of a 
fine network of coagulated fibrin, in 
which lie scattered pus corpuscles. 
The iris, J, is bounded in front by the 
anterior limiting layer, v, behind by 
the posterior limiting layer, h, and 
the retinal pigment layer, P. In the 
tissue of the iris are recognized the 
cross sections of blood-vessels, b, with 
very developed adventitia, and a 
great quantity of pigmented cells (the 
specimen is talcen from a dark-brown 
iris). Most of these stroma pigment 
cells still retain their elongated and 
branching shape, but others, at fc, are 
transformed into shapeless agglom- 
erations of pigment, as is usually the 
case in inflammation of the iris. In 
the anterior layers of the iris many 
small cells (emigrated leucocytes) — 
likewise an evidence of inflamma- 
tion—lie between the pigment cells. 



DISEASES OF THE IRIS AND OF THE CILIARY BODY. 291 

closes the pupil and is connected with the pupillary margin of the iris 
(Pigs. 93 and 93, e). This is called a pupillary membrane, and the 
condition thus brought about is called occlusio pupillm. It is evident 
that this condition must result in a very considerable impairment of 
vision. 

3. Exudation poured out into the posterior chamber is not accessible 
to direct observation, but manifests itself only by the adhesions which it 



[^^:p^^!«»j*.*pi7^i,,g5.^.i;',.;Sy^5:7:i 



^:;;/>:^/';:|^^Pi ^'■■' 



iP 



Fig. 91.— Recent Iritis with Pupillary Membrane. Magnified 55 x 1. 

The iris, i, is greatly thickened by swelling and infiltrated by numerous round cells. Attached 
to the pupillary margin is an exudate, e, which fills the whole pupil, and which, on the one 
hand, pushes its way somewhat beneath the pigment layer, p, and, on the other hand ex- 
tends up on the anterior surface of the iris. That it is a quite recent exudate is evident 
from its thickness and from its being composed of a network of fibrin, inclosing scattered 
pus corpuscles. The number of the latter increases toward the surface of the iris 




Fig. 92.— Occlusio Pupille Two Months after a Perforating Injury. Magnified 55 x 1. 

The exudate, e, has become converted into connective tissue, and has, in consequence shriveled 
down to a thin pellicle, which, becoming constantly more and more attenuated can be 
traced over the entire surface of the iris. The iris itself has become thinner from atrophy 
and where it ends at the pupillary margin is tapered oft owing to its being pulled upon by 
the pupillary membrane. The pigment layer, p, is the part most drawn out into the pupil 
so that it projects a good bit beyond the sphincter, s, and the stroma of the iris i Hence 
the margin of the pupil in the living eye, when looked at from in front, seems as though 
encompassed by a broad brown rim, which appears to attach the edge of the pupil to the 
capsule of the lens. 




Fig. 93. — Occlusio Pupill.^: Three Months after a Perforating Injury. Magnified 55 x 1. 

The exudate, e, is converted into a thin membrane of connective tissue, which, at the pupillary 
border of the iris, extends [somewhat over upon, but] mainly beneath the latter, and can be 
traced as a delicate pellicle for a long distance between the pigment layer, p, and the lens 
capsule, k. The tension set up by the pupillary membrane upon the border of the atrophic 
iris, i, has drawn the latter down over the pigment layer, so that the sphincter iridis, s, 
which is solidly united with the pigment layer, has its anterior border turned back in a 
hook-shaped bend. In the living eye the margin of the pupil appeared encompassed by a 
gray rim, which merged gradually into the less gray, because more transparent, pupillary 
membrane. 

causes between the iris and the capsule of the lens (posterior synechia). 
These adhesions develop principally at the spot where the iris and the 
capsule of the lens are in contact — i. e., at the pupillary margin. 
They form at the time when the iritis is at its height, and when, there- 
fore, the pupil is greatly contracted. When, after the iritis has run 
its course, the pupil tends to resume its usual mean width, this is only 



292 DISEASES OP THE BYE. 

possible over the area in which the pupillary margin has remained un- 
attached. The portions that are adherent to the capsule of the lens 
(au not retract, but remain as tags of greater or less size, projecting in 
toward the center of the pupil. The pupil thus acquires an irregular 
shape which is still more obvious if atropine is instilled ; for, as the 
iris then retracts strongly at its unattached portions, the synechia stand 
out in the clearest possible way (a and h. Fig. 94). Atropine is hence 
a very valuable agent for the diagnosis of posterior synechia. 

In the formation of posterior synechise, it is not the stroma of the 
iris, but the layer of retinal pigment (Figs. 91, 92, and 93, p) covering 
its posterior surface, that becomes adherent to the capsule of the lens. 
When the iris starts to retract, the pigment layer is held back at the 
points of adhesion, and is thus exposed to view more extensively than 
usual. Hence in dilatation of the pupil, especially by atropine, the 




Fig. 94.— Postbbiob SYNECHi.ffi: and the Remains of a Pupillary Membrane. 
Magnified 2x1. 

The pupil has been dilated by the instillation of atropine. The dilatation, however, is unequal, 
because the upper part of the pupillary margin is fixed by means of adhesions to the an- 
terior capsule of the lens. At a there is a slender synechia which is drawn out into a fine 
black point ; at fo, on the other hand, is found a broad and but slightly elongated adhesion, 
such as frequently occur, especially in syphilitic iritis. Between the synechiae and by the 
side of them, the capsule of the lens is covered with minute black dots arranged in a semi- 
circle. They correspond to the situation of the pupillary margin when the pupil was con- 
tracted and have been left by the rupture of the adhesions. From the lower part of the 
iris a filament, c, runs straight upward. This arises from the trabeculse of the cii-culus 
iridis minor, and passes in the region of the pupil to the anterior capsule of the lens, where 
it is attached to a small, round, capsular opacity. This filament is not a posterior synechia, 
but a remnant of the foetal pupillary membrane. It does not prevent the iris from' retract- 
ing properly under atropine, but is simply stretched and drawn out thin itself. 

tags jutting out into the pupil look brown. From the traction 
exerted by the iris, rupture of the synechise may result. This some- 
times is effected spontaneously by the traction which is constantly 
being made upon the adhesions during the ceaseless movements of the 
iris ; for the most part, however, rupture is produced artificially by 
the instillation of atropine. In that case we see, at the spot where the 
synechia has been set free, a brown spot remaining upon the anterior 
capsule of the lens. This is the pigment layer whose pathological 
adhesion to the capsule of the lens is firmer than its physiological con- 
nection with the tissue of the iris. If several synechia have been 
ruptured, we find remains of them in the shape of a corresponding 
number of brown dots arranged in a circle upon the anterior capsule 
of the lens (Fig. 94, between and on either side of a and h). This 
circle is narrower than the mean diameter of the pupil, because the 
Gynechise were formed at the time when the pupil was contracted by 



DISEASES OF THE IRIS AND OP THE CILIARY BODY. 



293 



iritis. The dots of pigment never disapi^ear, and hence during the 
whole life give evidence of an iritis that has once existed. 

If the adhesion of the iris to the capsule of the lens is not confined 
to single points, but comprises the whole extent of the pupillary mar- 
gin, we speak of an annular posterior synechia. No projecting tags 
are then apparent, because the iris is no longer able to retract at any 
spot, the pupil remaining unchanged all the time, even after the in- 
stillation of atropine. There is generally a brown rim (pigment) or a 
gray rim (exudate) investing the pupillary margin (Figs. 93 and 93). 
An annular synechia is seldom formed all at once ; it is for the most 
part the result of a number of recurring attacks of iritis, which little 
by little produce a more and more extensive adhesion of the iris to the 
lens. The direct consequence of an annular synechia is the shutting 
off of the anterior from the posterior chamber — shutting off of the 
pupil {seclusio pupillcB, Fig. 97). 

The two sequelas of iritis, shutting off of the pupil (seclusio pupil- 
lae) and shutting up of the pupil (occlusio pupills), very often occur to- 
gether owing to the fact that the exudate which attaches the pupillary 
margin to the lens may also extend over the entire pupil. But they 
may also occur separately and then have very different consequences. 
Occlusion of the pupil occurring by itself produces very great diminu- 
tion of sight, without, however, entailing any dangers for the future. 
Seclusion of the pupil in itself does not affect the sight, if the pupil ia 
free from membrane, but subsequently induces changes (increase of 
tension) which cause blinding of the eye. 

67. Symptoms of Cyclitis. — Exudation from the ciliary body, apart 
from the infiltration of the tissue itself, takes place into the anterior 
chamber, the posterior chamber, and the vitreous : 

1. The exudate produced by the ciliary body can get into the 
anterior cliamber in two ways: either directly, in case there is implica- 
tion of the most anterior portion of the ciliary body — i. e., that covered 
by the ligamentum pectinatum and lying at the confines of the anterior 
chamber; or indirectly, from the exudate being deposited first in the 
posterior chamber and then carried along with the aqueous through the 
pupil into the anterior chamber. 

A form of exudate that is found in many, especially the chronic 
cases of inflammation of the ciliary body, are Xh^ precipitates (deposits) 
upon the posterior surface of the cornea. These are small dots, no 
bigger than a pin's head, of a light gray or brownish color, which lie 
upon the posterior corneal surface {p. Fig. 97). They were formerly 
thought to be located in the cornea itself ; but if by puncturing the 
cornea the aqueous is allowed to escape, some of the deposits may be 
seen to disappear too, being swept away with the aqueous — a proof 
that they simply lie upon the posterior surface of the cornea. If the 
deposits are large, but few of them are generally present, and they are 



294 



DISEASES OP THE BYE. 



then commonly scattered irregularly over the cornea (Fig. 96 A). 
The smaller the deposits, the more numerous they generally are. 
They then occupy the lower half of the cornea, in which they cover a 
surface having the shape of a triangle. The base of the triangle cor- 
responds to the lower corneal margin, and its apex is directed upward 




Fig. 95.— Irtdo-ctclitis after Perforatino Injory. Magnified .30 x 1. 

In the drawing only a part of the anterior division of the eyeball ia represented. The cornea, 
C, and the sclera, S, are unchanged. Owirg to the fact that the aqueous is rich in fibrin, 
and hence is coagulated by the hardening fluids used, the anterior chamber. K, is filled with 
a dense network of fibrin, in which lie isolated round cells (emigrated white blood-corpus- 
cles). These round cells are particularly numerous upon the surface of the iris, and a-bove 
all in the sinus of the chamber; in fact, they fill the sinus completely, and form in it a low 
hypopyon which was visible in the living eye. A marked cellular infiltration can be seen 
surrounding Schlemm's canal and the cross sections of tlie anterior ciliary veins situated 
above the canal. The iris. I, appears broadened, as seen in cross section, this appearance 
corresponding with the swelling which existed in the living eye. Its vessels are dilated, and 
are distended with blood. In its stroma, particularly in the posterior layers, round cells are 
visible in great numbers : its retinal pigment layer is broadened and relaxed. The greatest 
emigration of cells has taken place from the blood-vessels of the ciliary body, the direction 
pursued being a centripetal one — i. e., toward the interior of the eye. Hence the infiltration 
in the ciliary muscle, M, is but slight, in the ciliary processes. P, it is rather more pro- 
nounced, and upon the surface of the latter it is the most marked of all, so that the outer 
limits of the processes are concealed by the dense masses of cells. The hyaloid membrane, 
H. is pressed away by the exudate from the surface of the ciliary body. The contents of 
the posterior chamber, like those of the anterior, are formed of a fine network of fibrin with 
round cells imbedded in it, these latter being found in specially large numbers along the 
hyaloid membrane. Two of the groups of fibers composing the zonule of Zinn are seen 
under the form of bright bands, passing through the coagulated contents of the posterior 
chamber to the lens, L. The latter displays the epithelium of its anterior capsule and the 
nuclear ring, and shows no morbid change. 



toward the center of the cornea. It is frequently observed that the 
deposits diminish in size from the base toward the apex of the triangle 
(Fig. 96 B). 

The peculiar arrangement of the deposits is readily explained by 
their mode of origin. The deposits are conglomerations of cells, 



DISEASES OP THE lEIS AND OP THE CILIARY BODY. 295 

agglutinated into masses by means of fibrin (Fig. 99). At first they 
are suspended in the aqueous, and by the movements of the eye are 
thrown by virtue of centrifugal force against the posterior surface of 




Fig. 96A. — Precipitates. 

Besides minute deposits, there are found also 
large ones, which are light gray and larda- 
ceous-Iooking. 




'. — Precipitates. 



These are small and disposed in the form of a 
triangle. 



the cornea and adhere to it. In so doing they arrange themselves 
according to weight, the largest being lowest down. The triangular 
shape of the arrangement is a result of the movements of the eyeball, 
by which the deposits are cast upon the cornea. We have only to 
think of what happens when we throw sand through a wire screen or 
shake grain in a sieve. The little fragments of stone or of grain 
always form a pointed figure with the apex, which contains the finest 
particles, running upward, while successively coarser particles follow in 




Tc r 

. Fig. 97.— Seclusion .and Occlusion of the Pupil. Magnified 5x1. 

The iris is adherent by its entire pupillary margin to the lens, but elsewhere is pushed forward. 
The posterior chamber, h, is thus made deeper, the anterior chamber, r. shallower, espe- 
cially at the periphery where the root of the iris, a, is pressed against the cornea by the 
increase of tension. In consequence of the traction made upon the iris, its retinal pigment 
is beginning to separate (at s) and to be left upon the capsule of the lens. The pupil is closed 
by an exudate membrane, o, by the shrinking of which the anterior capsule is throWn into 
folds. In the lower part of the anterior chamber there is matter, p, precipitated upon the 
posterior surface of the cornea. In consequence of the increase in tension, both the ciliary 
processes, c, and the ciliarj^ muscle, m, are atrophic nnd flattened. The cortex of the lens 
has undergone cataractous disintegration, and at r is separated from the capsule by liquor 
Morgagni ; the nucleus, fc, of the lens is unaltered. 



order below. The same is the case with the deposits. By their 
peculiar arrangement the deposits are generally easily distinguishable 
from macular opacities in the cornea itself (in keratitis punctata, see 



296 



DISEASES OF THE EYE. 



pages 184 and 193). Other distinguishing marks are the dearer out- 
line and frequently the brownish color of the deposits, which, more- 
over, do not lie at different depths like maculae in the cornea itself, 
but lie all in the same plane — that is, on the posterior surface of the 
cornea. 

That the deposits actually originate in the ciliary body and not in 
the iris is proved by the cases of pure cyclitis, in which deposits are 
present in abundance, although all symptoms of inflammation on the 
part of the iris are wanting. 

The exudate from the ciliary body, deposited in the anterior cham- 
ber, may also appear there under the form of hypopyon, just as in iritis. 
But what particularly characterizes cyclitis are the gray or grayish- 
white exudates that develop in many cases and which appear to grow 
out in the form of spongy masses from the sinus of the chamber, and 
that not merely, below, but also from other directions. 

2. In consonance with the anatomical situation of the ciliary body, 
the great mass of the exudate is deposited in the posterior cham- 




Fio. 98.— Total Posterior Synechia. Vertical Suction THRonoH the Eye. 
Maguifled B x 1. 

The iris is adherent by its poaterior surface to the anterior capsule of the lens and also to the 
anterior surface of the ciliary body. The posterior chamber consequently is obliterated 
and the anterior chamber deepened at its periphery. 6 ; at this spot the iris is strongly re- 
tracted and at the same time is here the most thinned through atrophy. The exudate con- 
necting the iris with the lens also stretches as a thin membrane, p, across the pupil. The 
hull of exudate, a, springing from the ciliary body, envelops the posterior surface of the 
lens and by its shrinking draws the ciliary processes toward the center. As a result of this, 
a separation of the ciliary body, c, from its bed has already taken place below, and in the 
intermediate space are seen the disjoined lamelte of the suprachorloid membrane, a. The 
pigment epithelium, /, of the ciliary processes has undergone proliferation. At tlie lower 
parp of the cornea there is a zonular opacity, g. The lens is swollen and is opaque through- 
out ; there Is no hard, undisintegrated nucleus (i. e., it is a soft cataract). 

ber. This exudation, if extensive, leads to the adhesion of the whole 
posterior surface of the iris to the anterior capsule of the lens {total 
posterior synechia, Fig. 98). This adhesion of the surface of the iris 
is distinguished from the annular synechia, in which only the pupillary 
border of the iris is attached to the capsule, chiefly from the altered 



DISEASES OF THE IRIS AND OP THE CILIARY BODY. 297 

form of the anterior chamber. The exudate, as it shrinks, draws the 
iris everywhere up to the anterior surface of the lens, so that the pos- 
terior chamber is completely obliterated. The anterior chamber is 
hence proportionately deeper, above all at the periphery, where the iris 
is displaced farthest backward {I, Fig. 98). 

3. Exudation into the vitreous appears under the form of opacities 
of the vitreous, which can be made out with the ophthalmoscope if 
the condition of the refracting media jDermits. Moreover, they mani- 
fest themselves by a corresponding diminution of the vision. In 
severe cases, an exudation of large size exists in the anterior division 
of the vitreous (s, Fig. 98), and under favorable circumstances can 
be seen with lateral illumination as a gray mass behind the lens. 
The sight is then almost completely abolished, and atrophy of the 
whole eye is subsequently produced by the shrinking of this mass of 
exudation. 

The tension of the eye, which in iritis is usually unchanged, often 
shows an alteration in cyclitis. It is not infrequently found to be ele- 
vated in the beginning of the cyclitis ; indeed, such a great elevation 
of tension may be developed that blindness is produced by it. In the 
later stages of cyclitis, on the contrary, diminution of the intra-ocular 
pressure is more frequent, and is the result of the shrinking of the 
exudate while in process of organization. 

Both iritis and cyclitis are associated with symptoms of inflamma- 
tory irritation, consisting of ciliary injection, photophobia, lachryma- 
tion, and pain. The pain is not only situated in the eye itself, but 
radiates to the parts in the vicinity, especially the supra-orbital region. 
The intensity of the irritative symptoms is regulated by the greater or 
less acuteness with which the case runs its course. Chronic cases occur 
in which inflammatory symptoms are wanting altogether, so that the 
eye is at no time reddened or painful ; on the other hand, there are 
cases of irido-cyclitis in which the pain reaches an absolutely intoler- 
able pitch and is associated with vomiting and a febrile movement. 
Sometimes the pain sets in with special violence at night (particularly 
in syphilitic iritis and irido-cyclitis). 

Vision is always diminished through turbidity of the aqueous or 
through exudation in the region of the pupil or in the cavity of the 
vitreous. 

Differential Diagnosis between Iritis and Cyclitis.— We speak of 
iritis if the symptoms enumerated above are present, and there is no 
direct proof of the participation of the ciliary body in the inflamma- 
tion. That the ciliary body is pathologically altered in most cases of 
apparently simple iritis is put beyond a doubt by anatomical investi- 
gations. But, since we can not see the ciliary body directly, slight 
changes in it escape diagnosis. We hence make the diagnosis of irido- 
cyclitis only in those cases in which in addition to the symptoms of 



298 DISEASES OP THE EYE. 

iritis positive evidences of involvement of the ciliary body are also 
present. This is the case — 

1. When the inflammatory symptoms reach a considerable pitch, 
and especially if oedema of the upper lid is associated with them — a 
thing which does not occur in simple iritis. 

3. When the eyeball in the ciliary region is painful to the touch. 

3. When deposits are present upon the cornea, or when the marked 
retraction of the periphery of the iris leads us to infer the existence of 
a total posterior synechia. 

4. When the disturbance of vision is more considerable than one 
would expect from the opacities within the confines of the anterior 
chamber. We are then justified in inferring the existence of opacities 
in the vitreous causing diminution of vision. 

5. If the tension is altered — either elevated or lowered. 

The participation of the ciliary body in the inflammation of the iris 
makes the disease a far more serious one and renders the prognosis 
worse. Not only is the . inflammation more violent, but it induces 
changes which are much more difiicult to remedy. The exudates, 
such as posterior synechias and pupillary membranes, produced by iritis 
in the confines of the anterior chamber, may be attacked successfully 
by operative procedures. But the exudates left by cyclitis in the vitre- 
ous, so far as they do not become absorbed spontaneously, are in no 
way susceptible of removal. Severe cyclitis leads to destruction of the 
eye (atrophy of the eyeball) — a thing that never occurs with iritis 
alone. 

Simple cyclitis * without iritis occurs but seldom, and that only in 
the chronic form. The infiammatory symptoms are slight or absent, 
the iris is of normal appearance, and the pupil is generally somewhat 
dilated. The chief symptoms are the presence of deposits upon the 
cornea and opacities in the vitreous. 

Inexperienced physicians often fail to recognize slight cases of iritis, con- 
sidering it as catarrh on account of the injection of the eyeball that coexists 
with it. The treatment then employed, such as the application of the silver- 
nitrate solution or the instillation of irritating collyria, commonly aggravates 
the iritis. We can avoid this mistake if in every case we pay careful attention 
to any discoloration that there may be in the iris (particularly by comparing it 
with that of the other eye), and also to the dimensions of the pupil, which in 
an eye with iritis is contracted. Moreover, a slight turbidity of the aqueous 
can be recognized, even in the early stages, from the fact that the pupil has 
not the same pure black look as in the other eye. On the other hand, the mis- 
take is often made of considering an inflammatory glaucoma as an iritis on ac- 
count of the ciliary injection and the discoloration of the iris — a mistake which 
is the more disastrous because in glaucoma great harm is done by the instilla- 
tion of atropine. Here, besides the testing of the tension, our chief means of 

* The serous iritis of authors. 



DISEASES op THE IRIS AND OP THE CILIARY BODY. 299 

guarding against mistakes is the examination of the pupil, which in iritis is 
always more contracted, in glaucoma always more dilated, than usual. 

In recent acute iritis and irido-cyclitis examination of the sight discloses 
sometimes the existence of a moderate degree of myop'ta, which did not exist 
previous to the inflammation, and which, moreover, gradually disappears again 
after the latter has run its course. 

A peculiar appearance is furnished by the presence of a pretty large /&?•«- 
nous exudate in the anterior chamber, such as is at times observed in every sort 
of acute iritis. If, for example, much fibrin is deposited in the aqueous, it 
may become coagulated into a uniformly gray, translucent mass (hence the 
name gelatinous exudate and also lenticular exudate, because with its rounded 
edges it sometimes looks like a half-transparent lens that has been dislocated 
into the anterior chamber). The exudate speedily shrinks, since the fibrin in 
contracting expels the liquid from its meshes (for which reason we also speak 
of it as a spongy exudate).* After a few days the exudate has either com- 
pletely disappeared or it has been reduced to a thin pellicle lying in the pupil 
and often still connected with the pupillary margin by one or two slender 
filaments. 

It happens sometimes that posterior synechife develop in the presence of a 
dilated, instead of contracted, pupil; as, for example, when they form in an eye 
under the infiuence of atropine. In this case the margin of the pupil becomes 
adherent to the capsule of the lens at some peripherally located spot, so that 
afterward, when the pupil assumes its mean width, the synechia is marked, not 
by a projecting process, but by a re-entrant angle. 

Por the diagnosis of seclusio pupillcB, the employment of atropine is indis- 
pensable. It often happens that the pupillary margin is thought to be adher- 
ent to the capsule all round, when, nevertheless, upon the employment of atro- 
pine it retracts at one small spot. At this unattached portion, which is most 
frequently situated above, there is thus formed a curved or horseshoe-shaped 
indentation of the pupillary margin. Similarly we may infer the existence of 
a small opening if, after the case has been under observation for a longtime, no 
protrusion of the iris takes place, since in true seclusio pujiillae such protrusion 
never fails to appear. Of course, we must be able to exclude the existence of 
a total posterior synechia, in which case evidently protrusion of the iris could 
not take place. 

Seclusio pupillse appears to occur frequently without, there being any simul- 
taneous formation of membrane in the pupil (occlusio pupillse). This, how- 
ever, is only apparent, as a rule. Upon careful examination we usually notice 
that the gray fringe of exudate which runs along the adherent pupillary margin 
projects far into the pupil, becoming gradually thinner as it does so, so that 
perhaps only the center of the pupil appears to be quite free. Nay more, if, 
after performing an iridectomy, we compare the pupil with the pure black colo- 
boma, we can almost always convince ourselves that really no part of the pupil 
is quite free from a membrane. 

Much more frequently than seclusion without occlusion, the converse— i. e., 
occlusion without seclusion— occurs. That is, there is a membrane in the pupil, 
and sometimes quite a thick one, which is not connected with the pupillary 
margin all round, but only at separate spots. 



[* Iritis associated with this sort of exudate is often called spongy iritis.— T).'\ 



300 DISEASES OF THE BYE. 

The presence of a well-marked reaction of the pupil to light is not altogethei" 
conclusive evidence against the existence of seclusio pupillse. If the tissue of 
the iris is not yet atrophic, and a fair perception of light at the same time exists, 
the anterior layers of the iris, when the illumination is varied, move quite per- 
ceptibly over the fixed posterior pigment layer. 

The deposits upon the posterior surface of the cornea are easily overlooked, 
because they are often so excessively minute. We should, therefore, in every 
case in which there is a suspicion of the existence of an affection of the uveal 
tract, look for them with a strong magnifying glass. In doing this we may 
in rare cases discover deposits upon the iris also and, within the pupillary area, 
upon the anterior capsule of the lens as well. Deposits are found not only in 
affections of the ciliary body, but sometimes also in those of the most anterior 
sections of the chorioid. 

I have quite frequently found minute deposits in eyes in which a soft cataract 
had been operated upon by discission, and was consequently swelling up and un- 
dergoing absorption at the time. These so-called lens dejjosits are, however, 
essentially different from the genuine deposits ; they are not agglomerations of 
exudation, but small rounded lens fragments, detached from the swelling lens 
and thrown against the posterior surface of the cornea, to which they then ad- 
here. They are therefore in no sense to be regarded as a sign of inflammation ; 
and this view of their nature is confirmed by the favorable course that sucli 
cases pursue. Other evidences of infiammation were wanting, and the subse- 
quent course in these cases furthermore was favorable. 

In severe cases of irido-cyclitis Cespecially of sympathetic origin) tlanching 
of the cilia on the lids of the affected eye is sometimes observed. 

Results of Anatomical Examination in Ikido-ctclitis. — Exudation into 
the tissue of the iris is characterized by the presence of numerous round cells in 
the latter, the quantity of which increases with the intensity of the inflamma- 
tion. Often they are not distributed everywhere alike, but collect in certain 
spots, especially along the vessels, so that circumscribed nodules of exudation 
are produced. This state of things is most strongly marked in syphilitic in- 
flammation, in which the nodules are often so large that they can be seen with 
the naked eye (papulse iridis). Within the ciliary body the cellular inflltration 
is much more profuse in the vascular ciliary processes than in the ciliary muscle 
(Fig. 95). 

The free exudate, deposited in the anterior chamber, in part sinks to the 
bottom of the chamber and forms a hypopyon, in part attaches itself to the 
walls of the chamber — that is, to the cornea, the iris, and the capsule of the 
lens. The thin coating of exudate, which covers the posterior surface of the 
cornea (Pig. 99, h and/), causes the latter in recent cases of iritis to appear slightly 
and uniformly clouded. It generally disappears with the subsidence of the in- 
flammation ; only in rare cases is the layer of exudation so considerable (espe- 
cially in the lower half of the cornea) that it afterward becomes organized and 
leads to the production of a lasting opacity of the cornea. 

The deposits are conglomerations of round cells many of which contain pig- 
ment granules (P, Fig. 99), thus proving their derivation from the uvea. They 
lie upon the endothelium of Descemet's membrane, which, at first, is perfectly 
normal and not till afterward becomes destroyed beneath the aggregations 
formed by the cells of the deposit (e, Fig. 99). The endothelium, therefore, 
has no more to do with taking an active part in the formation of the deposit 



DISEASES OF THE IRIS AND OP THE CILIARY BODY. 30I 

than any other part of the cornea. Accordingly, the terms formerly employed 
to designate the deposits, such as keratitis punctata, descemetitis, aquacapsulitis 
hydromeningitis,* which impute their place of origin to the cornea and more 
particularly to Descemet's membrane, are inapplicable. After lasting for some 
time the cells of the deposit undergo fatty degeneration and are absorbed 
while the pigment granules are left behind. Hence many deposits are seen 
to take on little by little a darker color until at length nothing but minute 
black specks are left at the place where they were situated. 

In many cases of irido-cyclitis, particularly those that are chronic, there are 
found specially large, gray, lardaceous-looking deposits, which as the disease 
progresses change their shape, enlarge, and coalesce with neighboring deposits 
to form biscuit- or trefoil-shaped masses of exudation (Pig. 96 A). Here, in 
contradistinction to the conglomerations of exudate that simply adhere to the 




P 

Fio. 99.— Deposit upon the Postekiok Sukpace of the Cornea. Magnified 140 x 1. 

™'^t?°?'*'""'' ™''f^'^<' of the cornea, C, is covered by Descemet's membrane, D. and the endo- 
thelium, e. The latter, which as a whole is of normal character, is wanting at the snot 
where the deposit, P, is situated. This deposit forms an accumulation of cells with inter- 
spersed pigment granules which are partly free and partly inclosed in the round cells In 
the place where no deposits are situated the posterior surface of the cornea is covered by a 
layer of exudation consisting of two strata, an anterior one, 6, composed of round cells and 
a posterior one, /, formed of coagulated fibrin. 

cornea, we have to do with independent foci of inflammation, in which, more- 
over, bacteria have been demonstrated to exist (Snellen the younger). 

The exudate that is poured out upon the anterior mrf ace of the iris displaces 
the endothelial membrane present there. The fate of this exudate depends upon 
its character. In the lighter cases, in which it consists chiefly of coagulated 
fibrin with only a few round cells (Fig. 90), it disappears comijletely by resorp- 
tion. In severe cases, the exudate is richer in cells and subsequently becomes 
organized. We then find the iris atrojihic and covered by a thin membrane of 
connective tissue (Pig. 93). The same is true of the exudation deposited upon 
the anterior capsule in the pupillary area, and of the exudates in tlie posterior 
chamber and in the cavity of the vitreous; in the light cases they are absorbed, 
in the severe ones they become organized into membranes, as will be more pre- 
cisely described in treating of the different modes of termination of irido- 
cyclitis. 

An anatomical classijication of irido-cyclitis has been based upon the varying 
anatomical characters of the exudate. In general, the exudates which are very 
poor in cells and are incapable of undergoing organization are called serous, 
those which are rich in cells and lead to the formation of adhesions and of 

* Descemet's membrane was r-alled capsula aquie, or, in Greek, hydromeninx, he- 
cause it was supposed to secrete the aqueous humor. 



302 DISEASES OF THE EYE. 

membranes are called plastic. Purulent exudates are those which contain very 
numerous cells with a fluid intercellular substance. Nevertheless, to classify 
irido-cyclitis, upon the basis of diflferences of this sort, into a serous, a plastic, 
and a purulent variety, is a procedure that has its difficulties and can not be 
carried out rigorously. In the first place, several kinds of exudation are often 
present at the same time; for instance, a purulent exudation constituting a 
hypopyon, and a plastic exudation forming synechise and pupillary membranes. 
In the second place, the macroscopic appearance of an exudation is by no means 
indicative of its pathological significance. This is particularly the case with 
regard to pus. Purulent iritis — i. e., iritis with hypopyon — which we so fre- 
quently find in connection with a corneal ulcer or with a foreign body im- 
planted in the cornea, often runs a very mild course and one devoid of ill con- 
sequences. We know, however, that the pus of such a hypopyon is free from 
micro-organisms. A very different significance, on the other hand, attaches to 
a purulent exudate containing cocci, which develops after the entrance of an 
infecting foreign body and causes destruction of the eye. A term to be alto- 
gether rejected is that of serous iritis, which is used by authors for those cases 
in which deposits are present while synechite are absent. The deposits, how- 
ever, are certainly not serous exudates, and, anyway, these cases are to be 
looked upon as examples of cyclitis, not of iritis. Because of all these reasons, it 
seems to me better to classify irido-cyclitis, not according to the kind of ex- 
udation, but according to the etiology, as will be done later on. 

In irido-cyclitis, the microscope generally establishes the fact of a partici- 
pation of the deep parts of the eye in the inflammation. The chorioid suffers 
the most injury, so that, when evident signs of its implication are present, we 
speak of irido-chorioiditis. But the retina too and the optic disk are almost 
never free from pathological changes in irido-cyclitis, although these changes 
are often too insigniflcant to be demonstrable by clinical examination alone. 

68. Course and Termination of Iritis and Cyclitis.— With regard 
to the course, a distinction is made between acute and chronic cases. 
The former are associated with marked inflammatory symptoms, but 
run a quicker course. But even in the acute cases — if we except the 
very lightest ones — it takes four weeks or more before the inflamma- 
tion entirely subsides. The first signs of a change for the better in the 
inflammation are the decrease of the injection and of the pain, and 
especially the prompt action of atropine, while at the acme of the in- 
flammation the pupil is so spasmodically contracted tliat atropine has 
little or no effect. 

Chronic cases run their course with few or absolutely no symptoms 
of inflammation. The patients, in the latter case, become aware of the 
existence of their trouble only at a comparatively late period, and then 
only from the increasing disturbance of vision. Chronic iritis (irido- 
cyclitis and irido-chorioiditis) is not infrequently protracted over a 
course of years. 

Inflammations of the iris and of the ciliary body often show a great 
tendency to relapse. Formerly the chief cause for the recurrence of 
the inflammation was supposed to lie in the posterior synechiae left by 



DISEASES OP THE IRIS AND OP THE CILIAEY BODY. 303 

the first attack of iritis. It was believed that in the constant movement 
of the pupil traction was contimially made upon the iris at the places 
of adhesion, and thus a new source of inflammatory irritation was pro- 
vided. But it has been demonstrated that relapses are to be appre- 
hended only in certain cases of posterior synechia. If, for instance, 
anybody has had an ulcer of the cornea, and, as a result of it, an iritis 
from which there are some synechias remaining, he need never fear 
having a relapse of his iritis. But another man who has got synechias 
as the result of an iritis with a constitutional basis (e. g., a syphilitic 
or rheumatic iritis) can very readily have recurrences. We hence con- 
clude that what produces the recurrences is not the synechias, but the 
continuance of the same constitutional cause that was accountable for 
the first attack of iritis ; and, as a matter of fact, we sometimes see a 
syphilitic patient sufEering from a recurrence of his iritis even when 
the first attack has got well without leaving any synechias ; or we see a 
recurrence affecting, not the eye that was previously diseased, but the 
other eye which has hitherto been sound. The recognition of the fact 
that one or two synechias are in themselves of no great significance has 
had an important practical result : the numerous operative methods 
designed for the. division of synechias have now been entirely given up. 

Kecurrences of iritis are often less severe than the primary inflam- 
mation ; but, as they are pretty frequently repeated, and as they leave 
a new exudate after them each time, they ultimately lead to serious 
changes, such as seelusio and occlusio pupillse. 

The outcome of inflammation may be a perfect cure in light cases. 
The synechias rupture, leaving behind bits of pigment attached to the 
anterior capsule, which are unproductive of injury to the eye. The 
hypopyon disappears by resorption. The deposits generally persist for 
a long time (for mouths), until they also are removed by resorption. 
In many cases they leave at the spot where they were situated a perma- 
nent opacity of the cornea in the shape of a gray speck, or the pigment 
that is contained in them remains permanently as a black dot. Slight 
opacities of the vitreous may also disappear completely by resorption. 

In most cases, however, permanent sequelm remain after iritis and 
cyclitis. These are — 

1. Atrophy of the /m.— This rarely develops after a single attack 
of acute iritis ; generally it is the result of repeated recurrences or of 
chronic inflammation. It is characterized by a bleached-out, gray, or 
grayish-brown aspect of the iris (resembling gray felt or blotting 
paper) ; the delicate markings of the anterior surface have disappeared, 
and in their stead dilated vessels can often be recognized as reddish 
blotches upon the iris. The pupillary margin is thinned down, often 
looking as if it had been frayed out ; the reaction of the iris is dimin- 
ished or altogether lost. The great friability of the atrophic iris often 
renders the correct performance of iridectomy impossible. 



304 DISEASES OF THE EYE. 

The most frequent and important sequelae are the exudates and ad- 
hesions which remain after nearly every case of iritis or irido-cyclitis. 
Among these are — 

2. Posterior SynecMm. — These, if only a few are present, cause no 
special injury to the eye, and also produce little or no impairment of 
sight Very much worse is the annular posterior synechia or seclusio 
pupillm. By this the communication between the anterior and the 
posterior chamber is obliterated. The aqueous secreted by the ciliary 
processes can no longer pass through the pupil into the anterior cham- 
ber ; it hence collects in the posterior chamber, pressing the iris for- 
ward (Pig. 97). A hump-shaped protrusion of the iris is thus pro- 
duced, which finally reaches as far forward as the cornea, while the 
pupil is represented by a crater-shaped retraction of the pupillary mar- 
gin which is attached to, the lens capsule. In consequence of being so 
greatly stretched, the iris becomes, atrophic. To this condition eleva- 
tion of the intra-ocular pressure (secondary glaucoma ; see § 86) is 
added. The increased hardness of the eye can be established by palpa- 
tion ; the anterior ciliary veins are dilated ; the cornea is dull and less 
sensitive to touch ; the sight fails, with a decrease in the field of vision 
starting from the nasal side, until at length the perception of light is 
entirely abolished. Then the formation of scleral ectasiae takes place 
in the blinded eye in the shape of anterior and equatorial staphylomata 
of the sclera. Seclusio pupillse, accordingly, if it is not remedied in 
time, infallibly leads to blindness. 

3. Pupillary Membrane {Occlusio Pupillm). — This causes an inter- 
ference with vision, the degree of which depends upon the thickness of 
the membrane. 

4. Exudates lehind the Iris. — These lie either between the iris and 
the lens (total posterior synechia) or between the ciliary body and the 
lens and upon the posterior surface of the latter. In severe cases they 
form a coherent fibrous mass which completely envelops the lens, and 
which, on account of its solidity, is called the cyclitic hull (s. Fig. 98). 
This has a great tendency to shrink. In total posterior synechia there 
is evidently no hump-shaped protrusion of the iris — on the contrary, the 
anterior chamber in the beginning is unusually deep at the periphery 
owing to the retraction of the iris (5, Fig. 98). Afterward, when atro- 
phy of the eye sets in, the anterior chamber often becomes shallower 
again, because iris and lens together are pushed forward. The exu- 
dates which lie behind the lens in the vitreous (c, Pig. 100) cause by 
their contraction a diminution of volume of the vitreous; the eyeball 
then becomes softer. The shrinking of the vitreous {g. Pig. 100) results 
in detachment of the retina (r) from the chorioid ; in part also this 
detachment is produced by direct traction, since the hull of cyclitic 
membranes as it shrinks attaches itself to the inner surface of the 
retina and draws it out of its bed. In consequence of the detachment 



DISEASES OF THE IBIS AND OF THE CILIARY BODY. 305 

of the retina, complete blindness ensues. This state of things, consist- 
ing of diminished tension of the eyeball, with decrease ia its size and 
with complete blindness, is known as atrophy of the eyeball. An atro- 
phic eyeball presents the following picture : The whole eye is smaller 
and of slightly quadrangular shape. This is because the four recti 
muscles, stretching across the equator of the eyeball, press the sclera in 
somewhat at this spot, and hence produce flattening at the four sides. 
With the higher degrees of atrophy quite deep furrows are formed, so 
that the eyeball has the form of a bale of goods grooved by the cord with 
which it is tied. The cornea is smaller, often opaque and flattened ; at 




FiQ. 100.— Atrophy of the Eyeball. (In part after Wedl-Bock.) 

The eye is smaller and of irregular shape, chiefly from the wrinkling of the sclera. S, behind the 
points of attachment of the ocular muscles, the rectus internus, ?■/, and the rectus externus, 
re. The cornea, C, is diminished in size, flattened, and wrinkled especially on its posterior 
surface. At its inner border it bears the depressed cicatrix, JV, which was produced by the 
in.iury. The anterior chamber is shallow ; the iris, ?, is thickened and forms an unbroken 
surface, because the pupil is closed by exudate. Behind the iris lies the shrunken lens, /, 
and behind this is the great hull of 'cyclitic membrane, c, the shrinking of which is the 
cause of the atropb.y of the eyeball. By reason of this shrinking, the ciliary processes, the 
pigment layer of which has markedly proliferated, are drawn in toward the center, and, 
together with the adjacent chorioid, c/l, are detached from the sclera ; between the two 
structures are seen the disjoined lamellae of the supi'achorioid membrane, a. The retina, r, 
is detached and folded in the form of a funnel, which incloses the remains of the degen- 
erated vitreous. The subretinal space, s, is filled with a fluid rich in albumin. The optic 
nerve, o, is thinner than usual and atrophic. 

other times, again, transparent, but abnormally protuberant or thrown 
into folds. The atrophic iris is either pressed quite against the pos- 
terior surface of the cornea, or an anterior chamber still exists. In 
the latter case, we find the chamber bounded behind by a firm dia- 
phragm in which the iris, which is imbedded in the hull of exudate, 
is often but indistinctly recognizable. If the pupil is still distin- 
guishable, a membrane and the opaque lens are found in it. The 
eye is softer, and is often sensitive to the touch. In the later stages 
20 



306 DISEASES OF THE BYE. 

markedly hard spots (ossified exudates) may sometimes be felt through 
the sclera. 

Atrophy develops gradually through a course of months and years. 
The inflammation and the pain, which have been present for a long 
time, disappear when the atrophy is complete. But even then sec- 
ondary attacks of pain occur, especially if the eye harbors a foreign 
body, or if ossification of the exudate takes place. 

5. Opacity of the Lens. — This develops in consequence of the dis- 
turbed nutrition of the lens. If merely a few synechise are present, it 
is rarely observed ; on the other hand, it is observed with proportion- 
ately great regularity when seclusio pupillse has existed for a long time, 
and particularly so in those severe cases in which the lens is completely 
swathed in cyclitio exudates. Such a cataract is denoted by the name 
of cataracta complicata or cataracta accreta (= grown fast to — i. e., 
grown fast to the iris). In atrophic eyeballs the lens is always opaque, 
and generally shrunken as well. 

Atrophy of the iris can progress to such an extent that the iris becomes 
transparent, or even so far that complete gaps form in it. A spontaneous 
formation of gaps in the iris is also sometimes observed when occlusio pu- 
pillse makes its appearance in early childhood. The iris is then fixed not 
only at its ciliary, but also at its pupillary margin, being attached to the mem- 
brane that exists in the pupil. As the eye grows, the iris is stretched con- 
stantly more and more between its two points of attachment until atrophy 
and finally dehiscence in spots occur. In this way, through the formation of 
an opening, the sight may be spontaneously restored. In like fashion, the for- 
mation of gaps (or even the separation of the iris from the ciliary margin) may 
take place in cases in which the iris was attached to a cicatrix of the cornea 
in childhood. 

The dilated vessels that are frequently visible in the atrophic iris, have quite 
often a course that does not in any way correspond with the regular radial 
arrangement of the normal vessels of the iris. As a matter of fact, vessels of 
this sort, as anatomical examination shows, do not lie in the iris itself, but in a 
thin exudative membrane deposited upon it. 

The protrusion of the iris does not take place uniformly, but with the forma- 
tion of projecting prominences separated by constrictions. The latter repre- 
sent the more resistant, radial fibers which do not give way before the pressure 
of the aqueous until afterward. The condition in which the iris is found pro- 
truding in a greater part of its circumference, while one sector of it remains in 
its normal situation, is generally referable to the fact that at this spot an adhe- 
sion of the surface of the iris to the lens exists, preventing its protrusion. It 
would, therefore, be a mistake to select just this spot for performing an 
iridectomy, although on other accounts it would seem to be very suitable 
for such a purpose, because of the greater depth of the chamber there. If 
the iris has been pushed forward as far as the cornea, it may become 
agglutinated to the latter in places, and in this way anterior synecbise may 
be produced without there having ever been a perforation of the cornea (see 
page 308). 



DISEASES OP THE IRIS AND OP THE CILIARY BODY. 307 

It should be remembered that seclusio and occlusio pupillse develop not only 
as the result of irido-cyclitis but also in connection with the larger perforating 
ulcers of the cornea if the margin of the pupil is incarcerated through its whole 
extent in the cicatrix. In this case, too, the usual consequences of seclusio 
pupillae make their appearance ; the iris is pressed forward as far as the cornea, 
and an increase in tension takes place, as is so often observed in staphyloma of 
the cornea (see page 315, and Figs. 60 to 63). 

The cornea in irido-cyclitis suffers harm through the deeply situated infil- 
trates that may form in it (see page 196), through the deposition of exudate 
(deposits, hypopyon), or through the contact of the iris, which when lasting a 
long time produces corneal opacity (page 196). In the stage of atrophy of the 
eyeball a zonular opacity frequently forms upon the cornea. Keratitis bullosa 
and vesiculosa also often make their appearance iii eyes which are blinded by 
irido-cyclitis. 

The anatomical changes, after an irido-cyclitis has run its course, manifest 
themselves under microscopical examination as follows: The atrophic iris is 
thinner than usual (Pigs. 93 and 93), and consists chiefly of fibrillary connective 
tissue. The cells of the stroma with their slender branches have been trans- 
formed in great part into coarse, round cells filled with pigment (k, Fig. 90) ; 
masses of pigment also are often found lying free in the tissue. The vessels 
are in part obliterated and the nerve trunks also have disappeared. The sphinc- 
ter pupillffi and the retinal pigments are the parts which remain the longest. 
The ciliary body, including both the ciliary muscle and the ciliary processes 
(Pig. 97, c), is also found to be atrophic in old cases. The two innermost layers 
of the ciliary processes, however, often undergo proliferation, the two strata of 
cells of the pars ciliaris retinas growing extensively into the cyclitic exudates 
(/) ^ig- 98). By the traction which the masses of exudate, as they shrink, exert 
upon the ciliary processes, the latter are greatly elongated, so that their apices 
project well toward their posterior pole of the lens ; when the traction is still 
greater, the entire ciliary body is pulled out of its bed (c, Pig. 98). This trac- 
tion upon the ciliary body is one of the causes of the continuous or constantly 
recurring sense of pain, which exists in so many cases of old irido-cyclitis and 
sets the patients almost frantic. 

The exudates themselves consist in the recent state of round cells and 
of an interstitial substance of fibrin, in varying proportions (Pigs. 91 and 
95). The exudates afterward become organized into false membranes, the 
round cells turning into spindle cells and ultimately into connective-tissue 
fibers. In this way a very tough tissue is produced, which grates when cut 
through, and which rightly bears the name of "hull." On account of this 
tenacity it puts great difficulties in the way of any attempts at the forma- 
tion of a pupil. In cases in which the irido-cyclitis has been produced by 
a foreign body, the latter not infrequently is found imbedded in this hull of 
exudate. 

Besides the above-mentioned tissue constituents there are often found in 
the exudation membranes new-formed blood-vessels which have developed from 
the neighboring organs, the iris and ciliary body, and also pigment which takes 
its origin from the retinal pigment layer of the iris and of the ciliary body. 
The lens which is inclosed in the exudation membranes forms with these a rigid 
diaphragm separating the anterior from the posterior section of the eyeball. The 
lens becomes opaque and disintegrates, its capsule ruptures, and masses of exu- 



308 DISEASES OF THE EYE. 

date penetrate into the capsular sac. If these masses afterward become ossified, 
the picture — to be sure only an apparent one — of ossification of the lens may be 
developed. 

By the subsequent shrinking of the exudation membranes, softening and 
diminution in size of the eyeball — atrophy of the eyeball — are produced. The 
anterior chamber becomes shallower, because the hull of exudate which is 
stretched between the ciliary processes and arches over the posterior surface of 
the lens («, Fig. 98) tends, as it shortens, to become approximated to a straight 
line (c, Fig. 100), and in so doing presses the lens forward. In other cases, on 
the contrary, the cicatricial traction may manifest itself more in a backward 
direction, so that the anterior chamber becomes deeper. Through the same 
force of traction cicatrices in the cornea or in the sclera, with which the exu- 
dates are connected, are drawn steadily inward {N, Fig. 100) ; hence the de- 
pression of cicatrices after injuries or operations is always to be considered a 
bad omen for the course of the disease. The traction of the exudates further- 
more causes detachment of the retina (r. Fig. 100) and often, too, detachment 
of the ciliary processes and even of the chorioid {cli). The cavity of the vitre- 
ous is reduced to a small space {g) lying directly behind the lens. The space 
beneath the retina (s) and also beneath the chorioid, wherever detached (a), is 
filled with an albuminous transudation and often also contains extravasated 
blood. In advanced atrophy, the sclera (S) is thrown into folds and is thick- 
ened in spots. The hull of exudate not infrequently becomes ossified later on, 
and, if the chorioid has participated in the process of exudation, the whole back 
part of the eye may be occupied by a shell of bone. The optic nerve is atro- 
phied to a thin strand of connective tissue. 

69. Etiology of Iritis and Cyclitis.— Iritis and cyclitis are either 
primary or secondary in tlieir development. In the first case, the 
original site of the disease is in the iris or ciliary body itself ; in the 
second case, there is an affection of neighboring parts, which has been 
transmitted to the iris and the ciliary body (e. g., in iritis with ulcer 
of the cornea). Primary inflammation of the iris and ciliary body as 
well as of the uvea in general is caused in the majority of cases by a 
deep-seated general disease, such as syphilis, scrofula, etc. In these 
cases both eyes are frequently affected, although not always at the same 
time. Furthermore, many of those cases which at present we still re- 
gard as purely local inflammations and which, because their origin is 
unknown to us, we designate as idiopathic, certainly belong in the same 
category. In proportion as our knowledge of the interdependence of 
morbid phenomena increases, the group of so-called idiopathic in- 
flammations of the uvea will melt away. Among the primary iritides 
the only ones of undoubtedly local nature are traumatic and sympa- 
thetic iritis. 

We may, therefore, classify the inflammations of the iris and the 
ciliary body with reference to their etiology according to the sub- 
joined scheme. In it, as well as in the subsequent description, the 
expression " iritis " stands for the sake of brevity as the representa- 
tive of iritis, cyclitis, irido-cyclitis, and irido-chorioditis— that is, for 



DISEASES OF THE IRIS AND OF THE CILIARY BODY. 



809 



all inflammations which predominantly affect the anterior part of 
the uvea : 



A. Primary 

iritis. 



Iritis in con- 
sequence of 
general dis- " 
eases. 



Iritis as a 
local affec- 
tion. 
B. Secondary iritis. 



1. Iritis syphilitica. 

2. Iritis scrofulosa. 

3. Iritis tuberculosa. 

4. Iritis rheumatica. 

5. Iritis gonorrhoica. 

6. Iritis in acute infectious diseases. 

7. Iritis diabetica. 

8. Iritis idiopathica. 

9. Iritis traumatica. 
10. Iritis sympathica. 



A. Primary Iritis.— 1. Syphilitic Iritis.— Syphilis is by far the most 
frequent cause of iritis, at least half of all the cases of iritis being ref- 
erable to it. For the most part, it is acquired syphilis that we have to 
do with. The diagnosis of syphilitic iritis is very easy in those cases 
in which the characteristic formation of nodules (iritis papulosa) is 
present. The nodules have a yellowish-red color, are of the size of a 
pin's head or larger, and are situated either on the ciliary or the pupil- 
lary margin of the iris, but never between the two zones in the mid- 
breadth of the iris. The nodules afterward disappear again by resorp- 
tion without any purulent disintegration taking place. At the places 
where they were situated, broad and solid synechia are left, and there 
is often also a circumscribed atrophy of the tissue of the iris. At 
other times no distinct nodules are found, these being so small that 
they lie concealed within the tissue of the iris, but several portions of 
the pupillary margin are greatly swollen, or at all events there are un- 
usually broad synechias which do not yield to atropine {b, Fig. 94). 
Finally, in many cases iritis syphilitica presents absolutely no charac- 
teristic marks ; the diagnosis, then, can be certainly established only 
by demonstrating the presence of syphilis, or the favorable action of 
antisyphilitic remedies. 

Syphilitic iritis generally belongs to the secondary stage of svphilis. 
It makes its appearance soon after the first eruptions upon the skin 
(macular or papular), for which reason we may compare the nodules in 
the iris to papules or to condylomata, and may designate the iritis as 
iritis papulosa. In most cases, the time when the iritis iirst appears is 
comprised within the first year after the infection has taken place. 
JMore rarely the iritis breaks out in the later stages of syphilis, and is 
tlien not associated with the formation of nodules. In exceptional 
cases, however, nodules do show themselves in this late form also and 
they must then be regarded as gummata (iritis gummosa). These are 
observed both in the iris and the ciliary body. They may attain great 



310 DISEASES OP THE EYE. 

dimensions, break through the envelopes of the eyeball, and bring about 
the destruction of the eye. 

Iritis also occurs in consequence of hereditary syphilis, although by 
no means as frequently as after acquired syphilis. Parenchymatous 
keratitis, dependent upon hereditary syphilis, is often associated with 
iritis. Sometimes it happens that the iritis becomes, comparatively 
speaking, very conspicuous, while the keratitis attains but a slight de- 
gree of prominence ; and there may even be iritis without any keratitis 
whatever. Iritis due to hereditary syphilis is a disease of childhood and 
youth, while iritis resulting from acquired syphilis is usually observed 
only in adults. 

Syphilitic iritis is very frequently associated with diseases of the 
posterior section of the eye — that is, with inflammation of the chorioid, 
retina, and optie nerve. Moreover, it displays a great tendency to 
recur. 

3. Iritis Scrofulosa. — This bears in its appearance and course much 
resemblance to iritis due to hereditary syphilis. It is often marked by 
the presence of large, lardaceous-looking deposits or by lardaceous exu- 
dation masses, which appear to grow out from the sinus of the cham- 
ber. It is found in the ages of childhood and youth in scrofulous per- 
sons, and also in those suffering simply from anaemia. 

3. Iritis Tuberculosa. — See § 74, Tumors of the Iris. 

4. Iritis Rheumatica. — This occurs in persons who have been ill 
with articular rheumatism (arthritis rheumatica). It is the form of 
iritis which has the greatest tendency to recur. From the fact that in 
many cases the recurrences of the iritis coincide with recurrences of 
the rheumatism (attacks of swelling in the individual joints), the con- 
nection between the two is demonstrated. Iritis also occurs as a result 
of arthritis deformans and arthritis urica [gout]. 

5. Iritis Gonorrhoica develops in those cases in which gonorrhoea 
has given rise to a general infection. This latter runs a course similar 
to that of acute articular rheumatism, but generally of a milder char- 
acter. As a general thing the knee-joint is the part first attacked by 
inflammation, which may afterward migrate to the other Joints also ; 
associated cardiac complications may even occur. This disease is 
known as gonorrhoeal gout [rheumatism]. Iritis does not generally 
set in until after the, outbreak of the arthritis, but there are cases in 
which gonorrhoea causes iritis alone and no disease of the joints. Just 
as the gonorrhoeal lesion of the joints is very similar to articular rheu- 
matism, so also gonorrhoeal iritis resembles in external features the 
rheumatic variety. Like the latter, too, it very frequently exhibits re- 
currences, with which is frequently associated a renewal of the discharge 
from the urethra or a return of swelling in the affected joints. 

6. Iritis in Acute Infectious Diseases. — Among these relapsing 
fever is the chief one in which iritis forms a frequent complica- 



DISEASES OP THE IRIS AND OF THE CILIARY BODY. SU 

tion. It is usually protracted in its course, but ultimately goes on 
to a cure. 

7. Iritis Diabetica. — This is often associated with copious exudation 
into the anterior chamber (hypopyon), but on the whole runs a favor- 
able course (Leber). 

70. 8. Iritis Idiopatliica. — Under this head are comprised those 
cases in which the inflammation apparently develops spontaneously in 
the iris, without its being possible to make out the presence of any 
local cause (traumatism, etc.), or of a constitutional affection. In 
many cases a cold is charged with being the cause of the iritis, but in 
most instances the cause remains obscure. 

Acute idiopathic iritis is generally unilateral ; it attacks none but 
adults, and those, in most cases, of the male sex. The iris of the adult 
man is much more prone to be inflamed than is the iris of the child. 
In childhood, therefore, iritis is rare anyway, and if no local cause (trau- 
matism, sympathetic ophthalmia, transmission from the neighboring 
parts) is present, the existence of a constitutional afllection can always 
be demonstrated. 

Chronic idiopathic iritis generally appears under the form of irido- 
cliorioiditis chronica (also called iritis serosa). This disease is associ- 
ated with but very slight symptoms of inflammation ; injection of the 
eyes and pain are present only now and then, and with but little inten- 
sity when they do exist ; frequently the only complaint that the patients 
make at all is in regard to the steadily increasing disturbance of vision. 
Examination of the eye shows posterior synechise which slowly increase 
in numbers until finally seclusion of the pupil is developed. Almost 
always too there is a thin membrane present in the pupil. The iris be- 
comes atrophic early, and afterward, when seclusion of the pupil de- 
velops, bulges forward in hump-shaped projections. Hypopyon is never 
present, but instead there are very frequently fine deposits which point 
to the implication of the posterior division of the uvea, an implication 
which also manifests itself through the presence of opacities in the vitre- 
ous. As these opacities continually increase in number and the vitreous 
at the same time becomes liquefied, the latter is finally converted into 
an opaque, mucilaginous liquid. Subsequently opacity of the lens is 
added, and atrophy of the chorioid and retina sets in. The interfer- 
ence with vision in these eyes is, therefore, always much greater than 
the optical obstructions in the anterior division of the eye (deposits, 
membrane in the pupil) would lead one to expect. This disease, which 
really affects all parts of the eyeball, in most cases terminates in com- 
plete blindness. In consequence of the seclusio pupills, increase of 
tension sets in with blindness from excavation of the optic nerve ; after- 
ward the eyeball may become ectatic. In other cases, blindness takes 
place under the guise of a gradually developing atrophy of the eyeball ; 
the eye becomes softer, and the retina undergoes total detachment. 



312 DISEASES OF THE BYE. 

Chronic irido-chorioiditis almost always attacks both eyes. It runs 
so slow a course that years pass before complete, blindness makes its 
appearance. It is a disease of advanced age, and is one of the most 
frequent causes of incurable blindness in elderly people, especially fe- 
males. The cause of it appears in many cases to be seated in bad nu- 
tritive conditions, or in early cessation of the menses ; but very often 
cases occur in patients who, apart from their eye trouble, are perfectly 
healthy. 

9. Iritis Traumatica. — The causes of this are traumatisms of all 
kinds, especially if perforation of the eyeball has taken place, and par- 
ticularly if a foreign body is left in the eye. Operations upon the eye- 
ball are, of course, to be counted among the traumatisms, and of these 
the most dangerous with regard to iritis and irido-cyclitis are the cata- 
ract operations. 

The irido-cyclitis that follows traumatism is frequently of the most 
serious nature, so that atrophy of the eyeball speedily ensues ; in con- 
tradistinction to iritis due to constitutional causes, which even when 
the inflammation is a violent one often gets well without leaving any 
ill results worth mentioning. 

With traumatic iritis and irido-cyclitis in the wider sense of an in- 
flammation produced by direct injury to the iris, may be also enumer- 
ated the following cases : Iritis frequently develops when, after open- 
ing the lens capsule, the masses of lens matter as they swell come into 
direct contact with the iris and 'press against it. The same is the case 
when there is pressure made upon the iris by a lens which is obliquely 
placed or completely dislocated. Finally, there might also be adduced 
in this connection those cases in which an intra-ocular tumor or 
cysticercus in a certain stage of development sets up a violent irido- 
cyclitis. 

The exciting cause of traumatic iritis in cases of the sort just 
adduced may be of three kinds : either mechanical injury (traction, 
contusion), chemical irritation (e. g., in the case of contact with swollen 
portions of the lens or in the case of a cysticercus) ; or, finally, infec- 
tion from without. The last-named cause is without doubt the most 
frequent. 

10. Irido- Gyclitis Sympathica. — When inflammation is carried from 
an eye suffering with irido-cyclitis over to the other side and attacks 
the other eye, which has hitherto been sound, the disease produced in 
the latter is designated by the name of sympathetic inflammation. 
This inflammation, like the primary one, makes its appearance under 
the guise of an irido-cyclitis. 

In the majority of cases iritis sympathica is preceded by a prodro- 
mal stage. The patient notices that during the performance of fine 
work he is suddenly obliged to stop because the work grows indistinct 
before his eyes ; after a period of rest he is again able to continue his 



DISEASES OP THE IRIS AND OF THE CILIAEY BODY. 313 

work. This interference with vision is caused by a weakness of the 
accommodation. Another symptom of the prodromal stage is sensitive- 
ness to light, and also, though not often, violent pain, the latter appear- 
ing sometimes at a portion of the eye which is symmetrically placed 
with reference to the diseased portion of the other eye. These symp- 
toms are also denoted by the name sympathetic irritation. They may, 
in rare cases, exist for years without inflammation supervening. In 
most cases, however, after a short time (from a few days to a few weeks) 
they pass over into manifest inflammation. 

Sympathetic inflammation declares itself by a development of the 
objective symptoms of irido-cyclitis together with an increase of the 
subjective troubles just described. Ciliary injection, contraction of the 
pupil, discoloration of the iris, and the formation of synechise are found. 
Deposits are almost never wanting, while, on the other hand, hypopyon 
is not ordinarily present. Minute opacities show themselves in the 
vitreous. These changes sometimes set in insidiously, sometimes sud- 
denly with great photophobia and considerable pain. In the severest 
cases the very first attack of inflammation induces annular or total pos- 
terior synechia and occlusion of the pupil ; in less severe cases it is 
possible, with suitable treatment, to effect after many weeks the disap- 
pearance of the inflammation, although a number of synechias are left 
behind. Unfortunately, after an interval during which the cure is ap- 
parently complete, a recurrence of the inflammation almost invariably 
sets in. By reason of this and subsequent recurrences the eye at length 
is destroyed, either as the result of increase of tension (due to seclusio 
pupillffi) or of a slowly developing atrophy. Those cases are to be 
classed as the exceptions which run so favorable a course that the 
patient gets off with a single attack of inflammation, and retains an 
eye with serviceable sight. 

The affection of the first eye, which gives rise to a sympathetic in- 
flammation, is always an irido-cyclitis, and is, in fact, almost without 
exception, an irido-cyclitis traumatica, due to a penetrating injury of 
the eyeball. All cases of traumatic irido-cyclitis are not equally fraught 
with peril for the second eye. To be regarded as particularly danger- 
ous are : (1) Those cases in which the injury has affected the region of 
the ciliary body, and particularly if it has left the iris or the ciliary 
body incarcerated in the cicatrix. For this reason, unsuccessful cases 
of Graefe's cataract operation have become a frequent cause of sympa- 
thetic inflammation. (3) Cases in which a foreign body has been left 
in the eye. 

The point of time at which the greatest danger of the transmission 
of the inflammation exists is when the irido-cyclitis in the injured eye 
is at its height. Hence sympathetic inflammation makes its appear- 
ance, in most cases, from four to eight weeks after the injury to the 
first eye has taken place. Later than this, when the traumatic irido- 



314 DISEASES OF THE EYE. 

cyclitis has subsided and the eye has fallen a prey to atrophy, there 
need be generally no fear of sympathetic inflammation so long as the 
atrophic eye is free from inflammation and is not painful, either spon- 
taneously or to the touch. The danger for the other eye does not de- 
velop again until the atrophic eye becomes once more the seat of in- 
flammation and of pain — an event which, to be sure, very frequently 
occurs. The most usual cause for these recurring attacks of inflam- 
mation is the persistent presence of a foreign body in the eye or the 
continual shrinking and ultimate ossification of the exudates. In this 
way an eye which has been carried for many years in an atrophic state 
without causing trouble may suddenly become the cause of a sympa- 
thetic inflammation. While, therefore, the minimum period for the 
development of sympathetic irido-cyclitis is a few weeks (the shortest 
period hitherto observed is ten days), no limits can be set to the 
maximum period ; sympathetic inflammation has been seen to appear 
forty years and more after the injury of the first eye. An eye which 
has been destroyed in consequence of injury is therefore a constant 
source of danger to the other eye. 

It is not necessary for the injured eye to be perfectly blind for it 
to excite sympathetic inflammation. Cases occur in which the eye has 
retained a remnant of visual power after the injury and the irido- 
cyclitis following it, and has yet given rise to sympathetic inflammation. 
In that case it may happen that the sympathetically affected eye un- 
dergoes complete destruction, while the injured eye is still used to 
see with. 

It is important to know — especially with reference to prognosis and 
treatment — under what conditions sympathetic inflammation of the 
second eye occurs only as a rare exception, and hence is generally not 
to be apprehended. These conditions are : 1. Phthisis cornese, due to 
suppuration of the cornea (after ulcus serpens, acute blennorrhcea, etc.). 
3. Staphyloma of the cornea. 3. Glaucoma absolutum. 4. Phthisis 
bulbi after panophthalmitis. 

In what way does the transfer of the inflammation from one eye to 
the other take place ? This question has not, up to this time, been 
definitely decided. Mackenzie was the first to direct the attention of 
physicians to the dependence of the inflammation of the second eye 
upon that of the first. His idea of the method of transmission was 
that the inflammation made its way backward along the optic nerve 
and passed over along the chiasm to the optic nerve of the other side, 
in which it traveled forward. This explanation was afterward given 
up, because the inflammation in the second eye made its appearance, 
not under the guise of an optic neuritis, but under that of an irido- 
cyclitis. Then, as the uvea is supplied by the ciliary nerves, the path 
of transmission was regarded as being in them. The ciliary nerves of 
the two sides are not connected with each other directly, as is the case 



DISEASES OF THE IRIS AND OF THE CILIARY BODY. 315 

with the optic nerves through the chiasm ; hence the transmission of 
inflammation in this case can not be conceived of as a direct one. On 
the contrary, we should have to assume that the ciliary nerves starting 
from the inflamed eye cause an irritation in the nerve center, which is 
transmitted like a reflex to the ciliary nerves of the other side and to 
their termination in the eye. 

Eecently many (Leber, Deutschmann, and others) have returned to 
the old theory of transmission through the optic nerves. It is supposed 
that, through the injury of one eye, micro-organisms are introduced 
into it and multiply there. Then they are supposed to travel along 
the optic nerve and its sheaths from one eye across to the other and to 
excite inflammation in the latter. 

B. Secondary Iritis and Irido-cyclitis are the varieties which develop 
through transfer of inflammation from neighboring organs to the iris 
and ciliary body. Inflammations of the cornea are the lesions that 
most frequently give rise to it; above all the suppurative keratides, 
which are very frequently indeed complicated with iritis. Of the va- 
rieties of scleritis, it is the deep form that leads to inflammation of the 
iris and the ciliary body. More rarely, inflammations pass forward 
from the posterior section of the eye to the iris. Among conditions 
that produce this result are chorioiditis and detachment of the retina. 
The iritides thus produced are usually of a lighter sort or are chronic, 
insidious forms. Finally, we may also put down under the head of sec- 
ondary iritis the cases of iritis traumatica, already adduced, in which 
the iris is not ailected by direct traumatism, as the iritis due to swell- 
ing of the lens, to luxation of the lens, to intra-ocular tumors, to cysti- 
cercus, etc. 

That form of iyphilitic iritis which is associated with the formation of 
nodules is generally designated under the name of iritis gummosa. For it was 
believed that these nodular exudates were necessarily to be regarded as gummy 
tumors on account of their sharply circumscribed form, which gives them some- 
times just the appearance of small neoplasms. If we agreed to this view we 
should have to ascribe this form of syphilitic iritis to the tertiary stage of 
syphilis, which is specially characterized by circumscribed exudates (gummata) 
resembling new formations. But in so doing we should be contradicting clini- 
cal observation, which shows that iritis with the formation of nodules always 
occurs simultaneously with the symptoms of the secondary stage. We are hence 
justified in comparing the nodules in the iris with the papules and condylomata, 
which also belong to this stage, and in designating the iritis as iritis papulosa 
or condylomatosa (Widder). Another argument against the gummy nature of 
the nodules in the iris is the fact that they never break down nor suppurate, as 
gummata are apt to do. True gummata of the iris do exist, however, but they 
are extremely rare. 

Apart from its physical signs, the diagnosis of syphilitic iritis will, of course, 
always have to be based upon the history of the case or upon the demonstration of 
the presence of syphilis in the patient. But should we call every iritis which has 
no characteristic marks syphilitic, simply because it occurs in a syphilitic person? 



316 DISEASES OF THE EYE. 

In the majority of cases, to be sure, we should be right, since syphilis is, in fact, 
the most frequent cause of iritis; but still a syphilitic patient may also acquire 
an iritis from any other cause whatever. In the absence of other guides, the in- 
dication in every case is to initiate an antisyphilitic treatment. This will, in 
most cases, cause rapid improvement in iritis of syphilitic origin, while other 
kinds of cases are but little or not at all affected ; from which fact a conclusion 
may be drawn as to the source of the iritis. The effect of antisyphilitic treat- 
ment is also of assistance in making the diagnosis in those cases in which we 
are in doubt as to whether a nodule in the iris is of syphilitic nature or must 
be regarded as a new formation (sarcoma, tubercle). 

Syphilitic iritis also occurs during intra-uterine life; the children then come 
into the world with the remains of it, such as synechise, occlusion of the pupil, 
atrophy of the iris, and even atrophy of the eyeball. 

As regards the acute infectious diseases, we find that, if we except relapsing 
fever, they only exceptionally give rise to iritis. We are acquainted with cases 
of iritis following pneumonia, intermittent fever, typhus, iniiuenza, variola, ery- 
sipelas, and mumps. The iritis, moreover, that sometimes accompanies herpes 
zoster, should probably be put down under this head. 

Of the chronic diseases, I have seen general alopecia sometimes accompanied 
by a severe irido-cyclitis ; and by many chronic nephritis is adduced as a cause 
of iritis. 

Some few cases are known in which a transient iritis with hypopyon recurred 
regularly with the menses in women. 

Sympathetic Ophthalmia. — The symptoms of sympathetic irritation which 
generally precede the inflammation are regarded by many as something entirely 
different from the latter and having no connection with it. They are thought 
to be produced through the ciliary nerves, while the transmission of the inflam- 
mation takes place through the optic nerves. It is adduced as a proof of the 
essential difference between irritation and inflammation that the former is cer- 
tainly and permanently relieved by the enucleation of the eye originally af- 
fected, while this operation is powerless against sympathetic inflammation. On 
the other hand, it can not be denied that in very many cases the symptoms of 
inflammation develop so gradually and imperceptibly from the symptoms of 
sympathetic irritation that no sharp line of distinction can be drawn between 
the two, and the inflammation appears only in the light of an exacerbation of 
the prodromal irritation. 

It is supposed that the sympathetic disease may appear not only in the form 
of an irido-cyclitis, but also under some other guise. The greatest variety of 
affections have been described as sympathetic. Among non-inflammatory affec- 
tions, cases of paralysis of accommodation, of amblyopia, and of blepharospasm 
have been adduced as sympathetic ; among inflammatory affections in the pos- 
terior division of the eye, neuritis, chorioiditis, and glaucoma; and in the an- 
terior division of the eye, conjunctivitis and keratitis. Most of these accounts 
are to be received with great caution, because observers have often gone too far 
in taking the sympathetic nature of the disease for granted. The fact that an 
eye has been destroyed through traumatism by no means justifles us in regard- 
ing, without further proof, any subsequent disease of the other eye as sympa- 
thetic. This assumption should be made only when such disease presents the 
characteristic clinical picture of sympathetic irido-cyclitis, or when, upon the 
enucleation of the eye first diseased, the symptoms in the second eye recede too 



DISEASES OF THE IKIS AND OF THE CILIARY BODY. 31 7 

rapidly to be accounted for upon any other assumption than that the afEection 
of the second eye was caused by that of the first. The converse of this inference 
does not hold good— that is, the fact that enucleation of the first eye does not 
influence the course of the disease in the second is no argument against the sym- 
pathetic nature of the lesion; indeed, it is a well-established fact that when 
sympathetic ophthalmia has once broken out, enucleation of the eye first dis- 
eased is not generally able to cause much change. 

Can an irido-cyclitis of non-traumatic origin be transmitted to the other eye? 
We very often see irido-cyclitis develop spontaneously first in one eye, then in 
the other. But we must not therefore at once conclude that the inflammation 
has been transmitted from one eye to tlie other. It may be that we have to do 
with a deeply seated common cause, generally of constitutional nature, which 
makes itself felt first upon one eye, then upon the other. Nevertheless, un- 
doubted cases of sympathetic inflammation have also been observed without any 
antecedent traumatism or perforation of the envelopes of the eyeball. In this 
category belong the instances of irido-cyclitis in the case of intra-ocular tumor 
and of cysticercus, in which the presence of a constitutional disorder as the 
common cause of the disease of the two eyes can be excluded. The fact de- 
serves mention that the wearing of an artificial eye over an atrophic stump may 
be the source of sympathetic inflammation through the irritation which it causes. 

In regard to the method of transmission of the inflammation, the view that it 
takes place by the way of the optic nerves is chiefly based upon the experi- 
ments of Deutschmann. In animals, it is not possible to excite by the injury of 
one eye a sympathetic inflammation in the other. Hence Deutschmann has em- 
ployed another method, namely, the injection of cultivations of fungi (especially 
of the staphylococcus) either into the eye itself or beneath the sheath of the 
optic nerve. He found that the fungi traveled from the site of injection along 
the optic nerves to the brain. At the base of the brain they made their way to 
the optic nerve of the other side, and passed down upon this to the eye. Here 
tbey set up an inflammation in the form of a neuritis of the intra-ocular end of 
the optic nerve, and with this, in one or two cases, an irido-cyclitis was as- 
sociated. The animals, moreover, speedily perished from general infection. 
Whether the inflnramation which Deutschmann produced in this way in the 
second eye is identical with sympathetic inflammation in man has not yet, to be 
sui'e, been certainly established. 

71. Treatment of Iritis and Cyclitis.— In every case of iritis and 
cyelitis it is incumbent upon us, on the one hand, to combat the local 
symptoms {indicatio morii) ; on the other, to remove the causes lying 
at their foundation {indicatio causalis). In those cases in which an 
etiological factor is not demonstrable, we are thrown back solely upon 
the symptomatic treatment. 

1. Symptomatic Treatment.— Airo^me is tlie most important rem- 
edy in iritis. Inasmuch as it contracts the iris, it necessarily dimin- 
ishes the amount of blood in its vessels, and hence directly counteracts 
the hyperaemia. By paralyzing the sphincter it fulfills a second indi- 
cation which requires every inflamed organ to be put at rest ; the con- 
stant to-and-fro movement of the pupil is completely arrested by 
atropine. The third action of atropine consists in its rupturing poste- 



318 DISEASES OP THE EYE. 

rior synechise which already exist and in its counteracting the forma- 
tion of new ones, through the dilatation of the pupil that it causes. 
The amount of atropine administered must be carefully regulated 
according to the degree of the intensity of the iritis. During the 
period of increase of the inflammation it is usually difficult to obtain 
dilatation of the pupil, because a spasm of the sphincter exists. In 
this case we must instill atropine several times a day. If this does no 
good, we place a little granule of atropine in substance in the conjunc- 
tival sac (for the necessary precautions, see page 276) ; this is better 
than to instill the solution too frequently, by doing which irritation of 
the conjunctiva (atropine catarrh) is readily set up. By the simul- 
taneous employment of cocaine the action of atropine may be height- 
ened. When the inflammation is abating, atropine is simply instilled 
often enough to keep the pupil constantly dilated. 

In cases of irido-cyclitis in which the implication of the ciliary body 
is particularly prominent, and also in cases of pure cyclitis, atropine 
is not always well borne. For, in proportion as the iris becomes nar- 
rower and its vessels can contain less blood, the vessels of the ciliary 
body are overdistended, since they have to take up the blood which 
finds no lodgment in the iris. Hence, in such cases, we must be very 
cautious in the use of atropine, and must suspend it whenever we find 
that the pain increases after the instillation. So also, when an irido- 
cyclitis is combined with elevation of tension, the atropine must be 
stopped and, if necessary, replaced by a miotic. 

In violent inflammation, moist warm compresses or poultices afford 
the best results, especially for the relief of pain. Cold compresses are 
generally not well borne, and are suitable only for recent cases of trau- 
matic iritis. 

Extensive bloodletting by means of six to ten leeches applied to the 
temple, or by a Heurteloup's artificial leech, may very greatly diminish 
the inflammatory symptoms in the bad cases ; not infrequently directly 
after such a bloodletting the pupil for the first time yields to the action 
of atropine, while before this it had remained in a constant state of 
spasmodic contraction. 

If the disease lasts a long time, the bloodletting may, if needed, be 
repeated once or twice. The production of profuse diaphoresis often 
has a very marked effect (see page 382). 

OpBrative proced^ires are for the most part indicated more in the 
sequelse of iritis than in recent inflammation. Paracentesis is per- 
formed whenever increase of tension sets in. It may also be tried in 
cases of long-persisting inflammation which will not yield to other 
remedies. As the aqueous escapes, the deposits upon the cornea are 
often washed out with it, and their escape can be facilitated by rubbing 
the cornea ; but the removal of such deposits is not the proper aim of 
paracentesis. Iridectomy is performed, but not while inflammation 



DISEASES OP THE IRIS AND OP THE CILIARY BODY. 319 

still exists, save in very exceptional cases, since if we perform it then 
we should have reason to fear that the newly made pupil would be closed 
up again owing to a continuance of the exudative process. Hence we 
undertake an iridectomy only when we are compelled to do so because of 
the development of an increase of tension, or as a last resort in order to 
put an end to the iritis when all other means have failed. Otherwise 
we wait until the inflammation has run its course, and then perform an 
iridectomy, either because a seelusio or occlusio pupillse has developed, 
or as a prophylactic in relapsing iritis to prevent further recurrences. 
And, in fact, in many cases, an end is put once and for all to recur- 
rences by this means ; in other cases, however, this successful result 
fails to occur. 

A proper regulation of the mode of life in iritis requires first of all 
protection from the light, not only on account of the photophobia that 
is generally present, but also because light excites the pupil to contrac- 
tion. For the latter reason the protection against light must be applied 
to both eyes, since with the contraction of the pupil of one eye that of 
the other also tends to contract. The patient is kejot in a moderately 
darkened room, or is made to wear dark goggles. This is better than a 
bandage, which it would be difficult to apply to both eyes. The patient 
should be moderate in eating and drinking, and should abstain from 
spirituous beverages. Care should also be taken to secure bodily rest 
by the avoidance of all physical exertion and in severe cases by rest in 
bed. The healthy eye should not be strained by reading, etc. More- 
over, it is important to see that the bowels move easily. 

2. Causal Indication.' — "With reference to the etiological factor, 
syphilitic iritis gives the most favorable prognosis, since it generally 
yields promptly to an energetic antisyphilitic treatment. The chief 
requisite here is promptness of action, since we are dealing with a lesion 
in which a few days may produce great and lasting damage (by the 
formation of a seelusio or occlusio pupillse). Hence mercury is selected, 
and this is best applied in the form of inunction (two to four grammes 
of blue ointment being rubbed in daily). The inunctions should be 
kept up until the diseased eye has become perfectly free from discolor- 
ation and then potassium iodide (up to three grammes a day) may be 
used for after-treatment. In iritis due to hereditary syphilis less 
value is attributed to specific antisyphilitic treatment and more to the 
strengthening of the organism as a whole. 

In iritis rheumatica sodium salicylate is administered, although 
not always with success. This drug also does good service sometimes 
in other forms of iritis, especially in iritis gonorrhoica and iritis dia- 
betica. In the former variety I have also employed with advantage 
the oil of gaultheria (fifteen drops per diem in capsules). 

In iritis traumatica the causal factor is first of all to be eliminated, 
in case it still continues to act. Foreign bodies are to be removed 



320 DISEASES OP THE EYE. 

from the iris ; portions of the iris that are much contused or are in- 
carcerated are to be excised. A swelling or luxated lens causing iritis 
must be removed from the eye. To combat the inflammation of the 
iris, iced compresses are employed in very recent cases in addition to 
the atropine. With respect to those traumatic iritides which follow an 
operation, the most important part belongs to prophylaxis. This con- 
sists in strict antisepsis during the operation ; and, as a matter of fact, 
since this has been employed such iritides have become much more 
rare. 

Irido-cyclitis sympatJiica, too, is very amenable to prophylaxis, while, 
when it has once broken out, it often resists treatment of every kind. 

{a) The only certain prophylactic treatment of sympathetic inflam- 
mation consists in enucleation of the eye which might give rise to 
it. This is the case in every eye which has been made blind by injury 
and is painful either spontaneously or upon pressure. Most emphati- 
cally requiring enucleation are eyes which are suspected to contain a 
foreign body. A contra-indication to enucleation is present only when 
the injured eye has still a serviceable residue of visual power or can 
get it through an operation. When this is not the case, enucleation 
should, under the circumstances above given, be performed without de- 
lay. At the utmost, if the patient can not bring himself to consent 
to enucleation, it is permissible to wait until the prodromal symptoms 
of sympathetic disease make their appearance, since even in this stage 
enucleation is generally still able to prevent the outbreak of sympa- 
thetic inflammation. 

(5) When sympathetic ophthalmia has already broken out, the efEect 
of enucleation is uncertain. In the lighter cases it appears to exert a 
favorable influence upon the course of the sympathetic inflammation ; 
in severe cases, on the contrary, it is often of no use and appears some- 
times actually to increase the inflammation in the second eye. Hence 
we wait for an abatement of the inflammatory symptoms in the second 
eye before performing enucleation. 

The sympathetic inflammation itself is to be treated according to 
general rules. Of especial importance is the protection of the diseased 
eye from light, which is most perfectly attained by long-continued 
bandaging of the eye. Operations generally give a bad result, since 
they start up the inflammation again, so that the newly formed pupil 
is once m.ore closed by fresh exudate. Hence operations are done only 
when it is absolutely requisite (e. g., when done on account of increase 
of tension) ; other operations, such as, for example, an iridectomy for 
optical purposes, are put off as long as possible, preferably for years. 

72. Treatment of the Sequelae of Iritis and Irido-cyclitis.— /so?fli!«i 
posterior synechim can often be ruptured by the employment of atro- 
pine either by itself or in combination with cocaine. Here it is not so 
much a long- continued action as a very energetic one that is required, 



DISEASES OF THE lEIS AND OF THE CILIARY BODY. 321 

and this is most certainly secured by placing atropine in substance in 
the conjunctival sac. Still more effectual sometimes is the alternate 
use of miotics and mydriatics, the pupil being first contracted with 
eserine, then suddenly and energetically dilated with atropine. But 
since the iris is made hyperasmic by eserine, attempts of this sort must 
not be made until some time has elapsed since the occurrence of the 
iritis. 

It is frequently possible to rupture synechise which are narrow and 
drawn out into a point, while broad synechise (such as occur after syph- 
ilitic or sympathetic iritis) withstand all attempts. 

Annular posterior synedda (seclusio pupillag) demands iridectomy 
unconditionally, the object being to restore the communication between 
the anterior and posterior chambers. The operation is often difficult 
on account of the shallowness of the anterior chamber (due to protru- 
sion of the iris), and also on account of the atrophy of the iris. Accord- 
ingly, we must often be contented if we succeed in making a small 
opening in the iris. Then the anterior chamber, in consequence of the 
restoration of the connection between the two chambers, regains its 
normal depth, so that a second iridectomy can be performed later under 
more favorable conditions. 

Total posterior synechia also requires iridectomy, which, however, 
is often void of result, as on account of the adhesion between the sur- 
faces of the iris and the lens it is frequently impossible to excise a suf- 
ficiently large piece of the iris, or because the pigment layer of the iris, 
which has grown fast to the lens, remains attached to it. In such cases 
the only thing to be done is to remove the lens, too, even if it is still 
transparent (Wenzel's extraction, see remarks to § 162). If the lens 
is atrophied or absent, iridotomy is indicated (see § 157). 

Too much caution can not be inculcated in regard to the senseless way in 
■which atropine is often used, as it still is, unfortunately, by many general prac- 
titioners, who instill ati'opine in every kind of eye disease. In many cases — e. g., 
in conjunctival catarrh — atropine is not only superfluous, but also causes the 
patient annoyance through the disturbance of vision produced by its use ; and 
in eyes which have a tendency to glaucoma, atropine may actually inflict 
great injury by determining an attack of acute glaucoma. Accordingly, atro- 
pine should be employed only upon quite specific indications, and should be 
applied no oftener than is requisite to obtain just the result desired. Even 
in iritis atropine is useless if the pupillary margin- is adherent to the capsule 
throughout, and the iris hence can not retract. 

If, after an iritis, one or two posterior synechias are left which do not rupture 
when atropine is energetically employed, we abstain from further treatment of 
them, since they generally do no harm to the eye. At the present time we have 
entirely desisted from releasing them by operation (corelysis). When, however, 
an annular synechia is present, we ought not to let it stay, but must make an 
iridedomy. This is also indicated in those cases in which the seclusion of the 
pupil is not yet indeed complete, but is on the verge of being so, only one small 
21 



322 DISEASES OF THE BYE. 

spot of the pupillary margin being free from it. For if we are dealing with a 
chronic irido-cyclitis, we can count upon this small spot soon becoming adher- 
ent too, and in that case it is better not to wait for the seclusion of the pupil 
to become complete. It is particularly advisable not to do so if the patient 
lives far from the physician, and might perhaps let the proper moment for the 
iridectomy pass by. 

In seclusio pupillas the iridectomy is made upward. If occlusio pupillse is 
simultaneously present, we should, according to the rules laid down for an op- 
tical iridectomy in § 155, make the coloboma to the inner side and below. But 
even in these cases it is advisable to make the iridectomy upward, because it is 
so often the case that the lens afterward becomes opaque, and in that case a 
coloboma situated above will be of advantage in performing the extraction that 
will be required later. 

In cases of chronic irido-chorioiditis, iridectomy is not only mechanically 
efficient by removing the seclusio pupillse, but it also has a favorable influence 
upon the entire nutritive condition of the eye. The vitreous clears up and the 
sight improves, often for quite a long time. If an operation is done upon eyes 
which have already begun to grow softer— that is, are on the road to atrophy — 
the eye in favorable cases fills out again, and the ocular tension becomes normal. 

Although enucleation generally afiords a sure safeguard against sympathetic 
inflammation of the other eye, nevertheless a series of cases is known in which, 
in spite of enucleation, inflammation has subsequently made its appearance. In 
every instance it has set in within a short time — from a few days to a few weeks 
— after the enucleation.* It must probably, therefore, be assumed that at the 
time of the enucleation the transfer of the inflammation had already begun. 
Yet even in this case enucleation does not fail to exert a favorable effect, since 
in the great majority of these cases the sympathetic inflammation runs an un- 
usually favorable course, probably because the removal of the first eye prevents 
the constant emission from it of new impulses for the production of inflam- 
mation. 

II. Injuries of the Iris. 

73. In addition to what has been already said in the previous, sec- 
tions in regard to injuries of the iris and their consequences, the follow- 
ing special varieties of injury, which are most frequently observed after 
contusions of the eye, may be mentioned : 

1. Under the name of iridodialysis f is designated the separation 
of the iris from the ciliary body. We then find on one side, at the 
ciliary margin of the iris, a black crescent which is formed by the sepa- 
ration of the iris from its insertion at this spot, so that we can look 
into the interior of the eye (Fig. 101). When the separation is pretty 
considerable, the edge of the lens (/), the ciliary processes (p), and the 
fibers of the zonula of Zinn stretching between the two can be recog- 
nized by means of lateral illumination in the gap that is thus produced. 
The pupil has lost its round form, owing to the fact that the pupillary 
margin toward the side of the iridodialysis has shortened so as to oc- 

* The longest interval so far observed has been thirty-two days (Snellen), 
f From Ipis, iris, and 5i<i\u<rij, separation. 



DISEASES OF THE IRIS AND OP THE CILIARY BODY. 323 

cupy the chord of an arc instead of the arc itself (Fig. 101, a). The 
cause of this inward displacement of the pupillary margin lies in the 
fact that the separated portion of the iris is stretched in a straioht line 
by the contraction of the sphincter. By this means it is withdrawn 
from its insertion in the ciliary body, and its reunion with the latter is 
rendered forever impossible. The sight is but little affected by irido- 
dialysis ; the only thing being that, if the eye is not accurately focused, 




Fia. 101.— Ikidodialtsis. Magnified 2x1. 

The pupillary margin at a is sloped off so as to form a straight line. At a point corresponding to 
this spot the ins is separated from the ciliary body and is narrower and somewhat wrinkled 
In the interval between the iri.s and the margin of the cornea are seen the margin of the 
lens, I, and the apices of the ciliary processes, p : the fine radiating striation between the 
two structures represents the zonula of Zinn. k, oirculus iridis minor : c, contraction fur- 
rows. 

monocular diplopia may occur, due to the formation upon the retina 
of an image both by means of the pupil and also of the peripheral open- 
ing (see § 122). 

Iridodialysis may occur to any extent, from a scarcely perceptible 
tear to complete separation of the iris from its ciliary attachment. In 
the latter case the iris rolls up into a ball which sinks to the bottom 
of the chamber, and which by the next day has shrunken into an in- 
conspicuous little gray mass. If a rupture of the sclera has been at 
the same time produced by the injury, the separated iris may be ex- 
pelled altogether from the eye through the scleral wound. In both 
cases complete absence of the his, irideremia* ov aniridia \ trauma- 
tica is produced. Again, a partial expulsion of the iris from the eye 
may occur, especially in cases of rupture of the sclera, and thus a trau- 
matic coloboma is produced. 

2. Radiating lacerations which start from the pupil. These may 
extend to the ciliary margin, so that the pupil at the site of laceration 
appears to be prolonged in the form of a pointed Gothic arch to the 
margin of the cornea (Fig. 102). Such large lacerations, however, are 
rare. Generally the pupillary margin is simply torn into a little, and 
the laceration gapes so slightly that it is discovered only upon careful 
examination, especially with the aid of a magnifying glass. Such small 
lacerations are tlie most frequent cause of the dilatation of the pupil 
{mydriasis traumatica) which develops after contusions and which is 
founded upon the weakening or paralysis of the sphincter due to the 

* From Ipis and iprtiiia, loneliness, want. f From h privative, and ?/)«. 



324 DISEASES OF THE EYE. 

laceration. In such cases, for the most part, a moderate dilatation of 
the pupil remains permanently. 

The ciliary muscle, too, may be paralyzed by a contusion, as mani- 
fested by the diminution of the amplitude of accommodation (recession 
of the near point). 

3. Inversion of the iris (Ammon) consists in its being turned back 
so as to lie upon the surface of the ciliary body (o. Fig. 103). The iris 
then can not be seen occupying its normal place, and looks as though 




FiQ. 108.— Radial Lacebations of the Iris. 

Above lies a large laceration, whose edges gape widely and whose upper extremity, which does 
not reach to the ciliary border, is rounded off. The smaller laceration, which lifts close to 
the larger one on the inner side of the pupil, retains its original acute-angled shape. The 
pupil is dilated, and obviously lacks the black rim of retinal pigment in that part of it« cir- 
cumference occupied by the lacerations. 

it were absent altogether. Total inversion of the iris is very rare. Par- 
tial dislocation backward is more frequently observed. At the spot 
where this takes place the iris seems to be wanting, and a coloboma ap- 
pears to exist just as if an iridectomy had been made. 

Injuries of the iris are generally accompanied by hsemorrhage into 
the anterior chamber. The blood which arises from the ruptured ves- 
sels of the iris sinks rapidly to the bottom of the chamber {hyplmma). 
and for the most part disappears by resorption within a few days, 
Then, and not before, are we able to investigate completely the damage 
which the iris has suffered from the injury, and we find perhaps an 
iridodialysis or radiating lacerations. But often even then it is impos- 
sible to discover a solution of continuity in the iris, and so the source 
of the bleeding remains unknown. In many of these cases the blood 
is supposed to come from a laceration of Schlemm's canal (Czermak). 

Treatment. — If the symptoms of irritation after the injury are par- 
ticularly marked, we apply iced compresses for several days ; in other 
cases it is sufficient to keep the injured eye under a bandage and to 
insure quiet on the part of the patient, secured, if need be, by rest in 
bed. If an iridodialysis can be made out, we instill atropine in order 
that the contracting sphincter shall not draw the iris farther away 
from its point of attachment ; in radiating lacerations, however, atro- 
pine is contra-indicated, because it would make the lacerations gape 
still more. For the reabsorption of large quantities of blood diapho- 
retic treatment may be initiated. Iritis is generally not to be appre- 
hended after injuries of the iris not connected with perforation of 



DISEASES OF THE lEIS AND OF THE OILIAEY BODY. 325 




Fig. 103.— Inversion of the Inis. 
Schematic. 

The cornea is flattened, and consequently 
the aqueous is pushed backward by the 
force which acts upon the center of the 
cornea. As a result of this, the iris in 
its lower part, u, bulges out in the form 
of a sac, but at its upper part, o, is com- 
pletely reversed, so as to point straight 
backward. 



the membranes of the eye. With reference to the treatment of per- 
forating injuries, see page 337. 

Iridodialysis is sometimes unintentionally produced in operations upon the 
iris. If the eye that is being operated upon makes a violent movement at the 
moment when the operator grasps the iris 
with the forceps, the iris may by this 
means be separated from its insertion to 
a varying extent, or even be torn out of 
the eye. Great haamorrhage into the an- 
terior chamber is always the result of this 
unfortunate accident. In iridectomy done 
on account of occlusion of the pupil, 
iridodialysis may also be produced in the 
following way : The operator grasps the 
iris and- tries to draw it out of the wound. 
To effect this it ought first to be set free 
from the pupillary membrane. But if the 
connection between the latter and the 
iris is very firm, the two do not separate, 
but the membrane and also the iris of 
the opposite side follow the course of the 
traction, so that an iridodialysis is pro- 
duced upon the side opposite the iridec- 
tomy. Hence, in such cases, the iris 
ought always to be first released from the pupillary membrane by lateral move- 
ments of the forceps before it is drawn out of the wound. 

Iridodialysis is produced in a non-traumatic way, when neoplasms of the 
ciliary body grow out into the anterior chamber so as gradually to push the iris 
away from its insertion (Fig. 105). 

To account for the above-described traumatic changes in the iris, two factors 
have to be taken into consideration. The first is based upon the flattening 
which the cornea undergoes through the contusion, and through which its cir- 
cumference and consequently also the circle of insertion of the iris become larger. 
If this enlargement takes place suddenly, the iris can not adapt itself to it and 
tears away in places from its insertion, so that iridodialysis is produced (Arlt). 
The second factor consists in the circumstance that the blow which strikes the 
cornea and flattens it out also pushes the aqueous backward. The latter tends 
to recede and pushes against the posterior wall of the anterior chamber, which 
in the area of the pupil is formed by the lens and in the rest of its extent by the 
iris. The latter, when pushed backward, finds a support in the lens except at 
the marginal portion of the iris which lies outside of the margin of the lens. 
Here the posterior chamber is deepest and is bounded posteriorly only by the 
feeble zonula of Zinn. The periphery of the iris, therefore, forms the most yield- 
ing spot in the posterior wall of the anterior chamber and the one which is the 
first to give way before the pressure of the receding aqueous. Hence the iris is 
bulged out backward by the aqueous so as to form a sac extending as far as the 
zonula, or, if this ruptures, extending even into the vitreous (Fig. 103, w). 
The direct consequences of this dislocation of